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bb^\y^> <br />Public Works <br />MaintenanceLocation of <br />Wastewater Connection 1820 Roosevelt Blvd. <br />Eugend, Oregon 97402 <br />(541) 682-4800 <br />W <br />Property Information <br />Address ___-------- <br />Map and Tax Lot__ <br />Building Type: gj SFD □ Duplex □ Multi-Family □ Commercial □ Industrial <br />Owner <br />Permit Information <br />Permit No. <br />Contractor/Plumber. <br />□ Right of Way Cut Permit Required <br />Installation Date \\ j --------- <br />PwmMan granM to attach prtnta <br />1 *\ — C* \________Date of Issue / \ W ^ u ^ <br />Pipft Mntfirinl ^ Pipe Diameter ^ ^ ^ <br />□ System Development Charge <br />Inspected By LlO^Q <br />h canbrmnanco to Oty aiandarda and •pvMcatkn*.connection to pubttc <br />Public Wastewater Information <br />Index Page No. <br />Inspected Bymi miSegment No.Contract No.Upstreom Downstream <br />TWO WORKING DAYS BEFORE YOU DIG, CALL UTILITY ONE-CALL SERVICE AT 1-800-332-2344 <br />1 <br />V <br />O om\f LORA'— H".c OR