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lablMf/4 <br />Public Works <br />Maintenance______ <br />1820 Roosevelt Blvd. <br />Eugend, Oregon 97402 <br />(541) 682-4800 <br />Location of <br />Wastewater Connection SCANME <br />Property Information <br />Address • <br />Map and Tax Lot__ <br />Building Type: <br />Wniprly St" <br />RtinriyOwner <br />^-SFD □ Duplex □ Multi-Family □ Commercial □ Industrial <br />Permit Information <br />Permit No. <br />Contractor/Plumber <br />□ Right of Way Cut Permit Required <br />Installation Date i 9 ~ 13 ~ l <br />\2zOk2jLLQl Date of Issue <br />Pipe Material A&S <br />11 <br />MPipe Diameter. <br />□ System Development Charge <br />. Inspected By <br />owwcttw to poMc t *t conformnanc* to C*y Handardm and wdlfarthn*Pwmhdon granM to attach prtvatt <br />Public Wastewater .Information <br />Index Page No.^—<3 0 <br />Inspected By <br />H(o0(oSegment Contract No.Downs tredm <br />TWO WORKING DAYS BEFORE YOU DIG, CALL UTILITY ONE-CALL SERVICE AT 1-800-332-2344 <br />/ <br />'/<s fc'l’ <br />/ <br />IH <br />Vt <br />I I <br />I <br />64'I <br />u>4e <br />QJ <br />3