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t bbl'A'}/f Z5 <br />l <br />Public Works <br />Maintenance&CANNELocation of <br />Wastewater Connecti 1820 Roosevelt Blvd. <br />Eugend, Oregon 97402 <br />(541) 682-4800 <br />•f <br />Property Information <br />Address ____:____ <br />Map and Tax Lot_Z <br />Building Type: <br />f^nr\A "Ttad L153,0 <br />E n r 14 LLr_______________:_____Owner <br />□ Duplex □ Multi-Family □ Commercial □ Industrial <br />Permit Information <br />Permit No. <br />Cnntrnntnr/Plumhfir ^~TEyCq.Ua~fiOtO Pipe Matftrinl 5ch. ^O <br />□ Right of Way Cut Permit Required <br />Installation Date 3 \ <br />1^-00163-0!Date of Issue 1 " I O / c7 <br />Pipe Diameter. <br />□ System Development Charge <br />-aCafse. Inspected By <br />h canformnorKt to CXy Handardm and iptcfrtcatfort*.Pwmhtlon grmtfd to attach ptivatm contfctfoa to puttk <br />Public Wastewater Information <br />51 <br />_ Inspected By Segment No.^L^g^Index Page No.Contract No. <br />TWO WORKING DAYS BEFORE YOU DIG. CALL UKUTY ONE-CALL SERVICE AT 1-800-332-2344 <br />37'