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bW<H V <br />\EDi— <br />Public Works <br />t Maintenance <br />11820 Ro.Osevelt Blvd. <br />Eugeni,- Oregon 97402 <br />(541) 682-4800 <br />Location of ; <br />Wastewater Connection •< <br />P^perty Information ^ Sf <br />___Owner . vrbMap and Tax Lot <br />Building Type: □ SFD □ Duplex ' □’Multi-iFamily □ Commercial .□ industrial • <br />Permit Information <br />Permit No. ' )<1' '01- <br />Contractor/Plumber L>pCo-------—— <br />□ Right of Way Cut Permit'Required <br />Date of Issue <br />_— Pipe Material-^..C H, VO i <br />□ System Development Charge <br />jLeuCdsSe. <br />//u <br />Pipe Diameter__ <br />Inspected ByInstallation Date <br />srcnM fa aUocti tvMt »mr corinteVcn to pubOa —wr *i confomncnc* to Oty ttorylani* aid iptctflcvVoc*. <br />atlon,Public Wastewater -Inform <br />Index Page.No.,—■ <br />Inspected By <br />Segment No.Contract No. <br />t <br />/a'Tja55 <br />\ <br />CoWrtcciKii'l C.I,e