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Public Works <br />MaintenanceLocation of <br />Wastewater Connection 1820 Roosevelt Blvd. <br />Eugend, Oregon 97402 <br />(541) 682-4800 <br />Property Information <br />Address —:—:------- <br />Map and Tax Lot — <br />Building Type: □ SFD ® Duplex □ Multi-Family □ Commercial □ Industrial <br />/31I <br />D Hift'TTOwner <br />Permit Information <br />Permit No. ~ ^ - O { — <br />Contractor/Plumber ^ <br />□ Right of Way Cut Permit^ Required <br />Installation Date <br />PmrmMon granted to attach prfvota <br />Date of Issue <br />Pipe MateriaL <br />□ System Development Charge <br />Inspected By ---------------------- <br />h ccnfarmnahc* to Oty ttandarda and tpacMcathna. <br />4>: /Pipe Diameter <br />75//- <br />Public Wastewater Information <br />Index Page No—— <br />Inspected By ---------------------- <br />xv.Downstream ContfOCtNo.Segment No. <br />TWO WORKING DAYS BEFORE YOU DIG, CALL UTIUTY ONE-CALL SERVICE AT 1-800-332-23+4 <br />l/>n n^i <br />4 <br />) <br />L° <br />/ <br />2 5'fO J <br />02Y)' <br />-%■ <br />L (/o t107 <br />t Sy <br />o m\