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V <br />•l <br />Location of • •. MF[70&jj <br />Wastewater Connection • • <br />Public Works <br />Maintenance <br />1820 Ro.Osevelt Blvd. <br />Eugeni,- Oregon 97402 <br />(541) 682-4800 ' <br />Property Information <br />Address -----—-— <br />Map and Tax Lot—: <br />Building Type: <br />*711 Ar^of\Avt <br />Owner HayrfP vn Home ^ Xnc . <br />: ^p-SFD □ Duplex "□'Multi-iFamlly □ Commercial. □ Industrial • <br />Permit Information <br />Permit No. | ^ ' Q^Sd'.Ql <br />Contractor/Plumber_i^ t"! L <br />□ Right of Way Cut Permit Required <br />Installation Date -----^ <br />..Pttmfstfon trvnfai to Mocfi prfwf* <br />__Date of Issue _________ <br />----Pipe Material Sc L- 0 Pipe Diameter <br />□ System Development Charge <br />LccCasS<L <br />11 <br />n(LVr\ <br />Inspected By <br />ctwcffofl to potOa h conAmrak* fa CHy ttarxfanfa and tp4cHfcctfcnt. <br />Public Wastewater .Information, <br />Index Page ..Not^^H-------- Segment No.. <br />Upstreom- OowTutraam Contract No. <br />T <br />Vt <br />3s <br />fe'clce?()tb5 <br />9^ <br />f-d'^