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H bMlHf- <br />1/■j <br />i. <br />Public Works <br />MaintenanceWastewater ConnectiSCANNEC <br />1820 Roosevelt Blvd. <br />EugenCi, Oregon 97402 <br />(541) 682- 4800 <br />th.Property Information <br />Address ____:____ <br />Map and Tax Lot — <br />Building Type: <br />no e.;K <br />OwnprAnna. fienjJand & iaaslotftL <br />□ Duplex □ Multi-Family □ Commercial □ Industrial <br />Permit Information <br />Permit No. _ <br />Contractor/Plumber <br />□ Right of Way Cut Permit Required <br />Installation Date <br />PwmJmkm granted to altocfi ptMHm <br />H-04<iaS‘-0 I Date of Issue // <br />Pipe Material Pipe Diameterii. <br />□ System Development Charge <br />SS<^.7 -[7--J-3 Inspected By <br />*i eanformnancm to Ofy itandardw and tpaddcaikn*.connection to putOc <br />Public Wastewater Information <br />Index Page No- <br />Inspected <br />\X1A imiUpstrean <br />LSegment No.Contract No.Downstroam <br />TWO WORKING DAYS BEFORE YOU DIG. CALL UTILITY ONE-CALL SERVICE AT 1-800-332-23+4 <br /><------//7' <br />13’ <br />1 o + <br />S' <br />9y Vg <br />Vg <br />13'/ <br />\