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bwn. <br />Location of ; • ■ 0f^L <br />Wastewater Connection fv // \3jj£j <br />Public Works <br />Malntgnance <br />1820 RoOsovelt Blvd. <br />Eugeni,- Oregon 97402 <br />(541) 682-4800 . <br />S ln,°rmat'°n 3HU clem^n uWy <br />Map and Tax Lol—^ T— — :—, Owner _ Lkmi0 Ki)•f(e.r <br />^TSFO □ Duplex "□ MultH-Family □ Commercial . □ IndustrialBuilding Type: <br />j <br />Permit Information <br />Permit No. _i___ ft Oxi^] <br />□ Right of Way Cut Permjt Required <br />Installation Date __) 9- '<s^ ~ 1 ------------- <br />ccnhicVon to pubOa <br />/J-3g-/gi?-oq~?3o-oi Date of Issue <br />Pipe Mnterinl qhPipe Diameter. <br />□ System Development Charge <br />L-<xf&sze <br />h ceofomiHrK* to Oty itortdarda and tpbcflhethrm. <br />Inspected By <br />, PmnMan gronM to attach prMo <br />■ Public Wastewater-Information.. • <br />Segment No. <br />Inspected B <br />^ SIM <br />Index Page .No.r Contract No. <br />Clemiori (/Jay(M o <br />37 <br />4-7~» <br />”1