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bbbOi <br />5 . <br />5 Public Works <br />Maintenance <br />1820 Roosevelt Blvd. <br />Euqend, Oregon 97402 <br />(541) 682-4800 <br />Location of <br />Wastewater Connection <br />Property Information <br />Address —:—Li------- <br />Map and Tax Lot — <br />Building Type: ©SFD □ Duplex □ Multi-Family □Commercial □ Industrial <br />/ iOwner <br />Permit Information <br />Permit No._1--------- <br />Contractor/Plumber. <br />□ Right of Way Cut Permit Required <br />Installation Date <1 ~ -------- <br />Date of Issue________^ <br />Pipe MaterialPipe Diameter 4>_ <br />arge <br />- <br />□ System DevelopmentXhi <br />Inspected By ____ IjiL <br />h confarmnenct to CXy standard* and •p*cf/icaiion*.conycifoa to pubOcPtrmMon gmnM to aiioc/i prtoata <br />Public Wastewater Information <br />Index Page No- <br />Inspected By <br />Segment No.Contract No.DownstreamUpstream <br />TWO WORKING DAYS BEFORE YOU DIG, CALL UTHJTY ONE-CALL SERVICE AT 1-800-332-2344 <br />z) pi/feu c Co <br />Mu A-536^9 <br />/ Nei^ ) <br />\ <br />PA t 1 <br />P5100