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H-'r/ <br />i <br />SCANNER Public Works <br />Maintenonce_____' <br />1820 Roosevelt Blvd. <br />Eugend, Oregon 97402 <br />(541) 682-4800 <br />Location of <br />Wastewater Connection <br />Property Information <br />Address • <br />Map and Tax Lot_: <br />Building Type: <br />l-(68<? RoWK/ cA. <br />Owner <br />□ Duplex □ Multi-Family □ Commercial □ Industrial <br />Permit Information <br />Permit No. _ <br />Contractor/PIumber E-XC. Pipp, Materinl 5<lh-WO Ripe Dinmeter <br />-S-3.VITDate of Issue • » <br />□ Right of Way Cut Permit Required <br />~j~ ii- n <br />□ System Development Charge <br />Installation Date <br />Ptrmlmlon granM to attach pthoto «—w cennictfon to pubOc r*wtr h ccnformnanc* to CHy ttondarxii and iptcMcaHortA. <br />Inspected By <br />Public Wastewater Information <br />Index Page No.^ <br />Inspected By <br />Segment No. jg&Tj/£3 Contract No. <br />TWO WORKING DAYS BEFORE YOU NG. CALL UTILITY ONE-CALL SERVICE AT 1-800-332-2344 <br />> 3^'<e-io3 <br />N <br />i <br />l <br />\/?