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bbbO\s <br />\ <br />Public Works <br />MaintenanceLocation of <br />Wastewater Connection 1820 Roosevelt Blvd. <br />Eugeng, Oregon 97402 <br />(541) 682-4800 <br />Property Information <br />Address _______ <br />Map and Tax Lot__! <br />Slv^ <br />Building Type: ^SFD □ Duplex □ Multi-Family □ Commercial □ Industrial <br />wner <br />Permit Information <br />Permit No. <br />Contractor/Plumber_^Jlidi£5__PlvJWib/ <br />□ Right of Way Cut Permit Required <br />Installation Date <br />P^rmktkn gnnttd to attach prtvato <br />\C\' oilD$-o \Date of Issue /O V~/ ? <br />ipe MaterialHO V"t Pipe Diameter. <br />□ System Development Charge <br />L-a.Inspected By <br />h conkumnonca to Ctty ttandarda and tpacHtcatfan*.cannactbn to puttie <br />Public Wastewater Information <br />Index Page No. <br />I BmeSegment No.Contract No.ipstreom <br />TWO WORKING DAYS BEFORE YOU DIG, CALL UTILITY ONE-CALL SERVICE AT 1-800-332-2344 <br />T <br />15' <br />Iq %l3e <br />-tT % <br />I