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!s; bb$si <br />Public Works <br />MaintenanceWastewater ConnecticSCANN <br />1820 Roosevelt Blvd. <br />Eugeni, Oregon 97402 <br />(541) 682-4800 <br />Property Information <br />Address ____:_____ <br />Map and Tax Lot___I <br />Building Type: ^jhSFD □ Duplex □ Multi-Family □ Commercial □ Industrial <br />Owner <br />Permit Information , _ <br />Permit No. I S ~ <br />Contractor/PlumberO Pipe Material h ^ Pipe Diameter—/ <br />□ Right of Way Cut Permit Required <br />Installation Date __3-o(£> - Z 9____ <br />a ■aZ’-nDate of Issue // <br />□ System Development Charge <br />Lo, CfiZSG.Inspected By <br />In ccnformnonc* to CXy atandordr and tpocHhotiona.Ptrmhtkn granted to aitoch pftmto —war eennoeVoa to pubOc <br />Public Wastewater Information <br />Index Page No. <br />n Inspected By - <br />Segment No.Contract No. <br />TWO WORKING DAYS BEFORE YOU DIG, CALL UTTUTY ONE-CALL SERVICE AT 1-800-332-2344 <br />\lo9' <br />A/3-3' <br />&■ <br />3 <br />a' <br />^ , <br />7