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I; bb^Sr <br />Public Works <br />MaintenanceLocation of <br />Wastewater Connection 1820 Roosevelt Blvd. <br />Eugend, Oregon 97402 <br />(541) 682-4800 <br />Property Information <br />Address _____:____ <br />Map and Tax Lot — <br />Building Type: ^LSFD □ Duplex □ Multi-Family □ Commercial □ Industrial <br />Uooaln'TOwner3 <br />Permit Information <br />Permit No. 1 ^ 1 I Date of Issue <br />Material Mf) <br />/' <br />Diameter^gCnntraator/Plumber Pi OmV^inpPipft <br />□ Right of Way Cut Permit Required <br />Installation Date <br />Pipe <br />□ System Development Charge <br />LaXasseq-iq-iq Inspected By <br />connection to public T ht contormnanc* to CHy itandordm and *p*cHfcatton*.Pmrnkakm fronted to attach private <br />Public Wastewater Information <br />I3(oA 2dnsplfm_ <br />Downstream Contract No.Index Page No-Segment No.Upstream <br />TWO WORKING DAYS BEFORE YOU DIG. CALL UTILITY ONE-CALL SERVICE AT 1-800-332-2344 <br />OtT<> <br />i <br />■\ <br />•i ■ <br />H 33 <br />I S'3 <br />4-:\n <br />tn <br />—oc <br />QJ <br />t. <br />\Yt <br />\hb