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_______ <br />r" b Public Works <br />MaintenanceLocation of <br />Wastewater Connection 1820 Roosevelt Blvd. <br />Eugene, Oregon 97402 <br />(541) 682-4800 <br />Property Information <br />Address ____:—:— <br />Map and Tax Lot — <br />Building Type: □ SFD <br />0#^ A )^r 3^77^ Asp <br />_______________:__,__Owner --------:------------------:---------- <br />□ Duplex □ Multi-Family □ Commercial □ Industrial <br />Permit Information <br />Permit No._______ <br />Contractor/Plumber. <br />_Date of Issue <br />.Pipe MaterialPipe <br />□ System Developmenjt Charge <br />. . Inspected By ____________— <br />ccnyctko to puMc Mow *t conkrmnonc* to Oty itandardw am! •ptcHIcaihn*. <br />iDiameter <br />(□ Right of Way Cut Permit Required <br />5-£0 -/tfInstallation Date <br />Ptrmhtlan grantod to attach prtwtm <br />Public Wastewater Information <br />Index Page No. <br />Inspected By <br />Segment No.Contract No.Upstream Downstream <br />TWO WORKING DAYS BEFORE YOU DIG, CALL UTILITY ONE-CALL SERVICE AT 1-800-332-23*4 <br />4 - <Sf <br />o <br />tv* <br />tJ <br />Iji/esr hisTfr fat