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bbblZ'1/' <br />Public Works <br />MaintenanceLocation of <br />Wastewater Connection 1820 Roosevelt Blvd. <br />Eugeni, Oregon 97402 <br />(541) 682-4800 <br />Property Information <br />Address ___-------- <br />Map and Tax Lot — <br />Building Type: <br />llSI Rr|, <br />(aJ&AtOwner <br />^SFD □ Duplex □ Multi-Family □ Commercial □ Industrial <br />Permit Information <br />Permit No.__ <br />Contractor/Plumber lOfl-ll __ <br />□ Right of Way Cut ^Permit Required <br />Installation Date —^ ^------------- <br />PwmMon granted to attocA tvAafo mmt connection to pubOc <br />iq- on/^-o s-is-nDate of Issue '/ <br />Pipe Material ABC^^-^VPipe Diameter--/^ <br />□ System Development Charge <br />Inspected By <br />h confocmnonce to CXy tiandardt and wpocllkatloif. <br />Public Wastewater Information <br />Index Page No. <br />Inspected By <br />Segment No f&Joi4*1 Contract No.Downstreamtream <br />TWO WORKING DAYS BEFORE YOU DIG, CALL UHUTY ONE-CALL SERVICE AT 1-800-332-2344 <br />£ <br />I <br />5 <br />y$ <br />i <br />f15o