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blz'A'lS]NED Public Works <br />MaintenanceLocation of <br />Wastewater Connection 1820 Roosevelt Blvd. <br />Euqend, Oregon 97402 <br />(541) 682-4800 <br />Property Information <br />Address _;_— <br />Map and Tax Lot <br />Building Type: ^SFD <br />Awe767An <br />Owner <br />□ Duplex □ Multi-Family □ Commercial □ Industrial <br />Permit Information <br />Permit No. <br />Contractor/Plumber_j: <br />□ Right of Way Cut Permit Required <br />Installation Date ___^ ~ t~ 1.3--------- <br />PamMon orvnM to attach prt*ota moor connection to piMh aaaar h confarmnanca to Ctty itandarda and •pacMcatlont. <br />f) rtnA L <br />ftDate of Issue <br />Pipe Mntfirinl Sc\o.MO Pipe Diameter^OOlVY^ <br />□ System Development Charge <br />Inspected By La CazSe <br />Public Wastewater Information <br />Index Page No., <br />Inspected By — <br />IbOOd- 'A <br />Downstream7)H Segment No.Contract No.Upstream <br />TWO WORKING DAYS BEFORE YOU DIG, CALL UTILITY ONE-CALL SERVICE AT 1-800-332-2344 <br />N <br />Y*i J <br />Y? <br />r <br />I <br />Y? <br />°1 <br />6 i 73\