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fv--- <br />5', <br />i:•: <br />4 <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 —1_ <br />Map and Tax Lot <br />Building Type: <br />c. p7gpri/e < <br />FD □ Duplex □ Multi-Family □ Commercial □ Industrial <br />Owner <br />Contractor/Plumber__ty4-OtA_• <br />□ Right of Way Cut Permit Required <br />Installation Date <br />Ptml—lcn granted to attach prlvata <br />Date of Issue 17 /f <br />Pipe Material 40 Pipe Diameter ' <br />□ System Development Charge <br />Inspected By ___L-<X Q^t <br />ki ccnformnonc* to CHy ond tp+cf/kations. <br />q-B-zq <br />coonacVoa to public <br />Public Wastewater Information <br />Index Page No—2-7 ^nspecr^-\ <br />DownstreamSegment No.Contract No.Upstream <br />TWO WORKING DAYS BEFORE YOU DIG, CALL UTILITY ONE-CALL SERVICE AT 1-800-332-2344 <br />T" <br />H cV <br />\o <br />schMD H" <br />s\/^r <br />H' <br />cs> <br /><-)oV ^ir