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bb^br-ifs <br />i <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: <br />} <br />\a/<s Dr _____ <br />Kri -1-n vi(x ( a r <br />□ Duplex □ Multi-Family □ Commercial □ Industrial <br />Owner <br />Permit Information <br />Permit No. _____- -__________ <br />Contractor /Plumber Ufa-UH ■ <br />ao-oizis'-'oi'3'3-30Date of Issue_______. <br />Pipe Material Pipe Diameter_I <br />□ System Development Charge <br />. Inspected By ______L-a (La £____ <br />PwmkaloH grant*! to attocfi prtvoto ••nr connocdoa to pubtSc nnr h conformnanco to Ctty •iandardw and tpocHhaHorta. <br />U <br />□ Right of Way Cut Permit Required <br />Installation Date ___<3 '\~1 ~ <20_ <br />Public Wastewater Information <br />5ZIIndex Page No.Segment No.Contract No. <br />TWO WORKING DAYS BEFORE YOU DIG, CALL UTILITY ONE-CALL SERVICE AT 1-800-332-2344 <br />N <br />I