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Public Works <br />MaintenanceLocation of <br />Wastewater Connection 1820 Roosevelt Blvd. <br />Eugend, Oregon 97402 <br />(541) 682-4800 <br />■3ISTO prJWd \a],Property Information <br />Address ___— <br />Map and Tax Lot <br />Building Type: <br />~Th wia fa. Mr H if lift <br />SFD □ Duplex □ Multi-Family □ Commercial □ Industrial <br />Owner <br />/ <br />Permit Information <br />Permit No. <br />Contractor/Plumber l^CiTO. <br />□ Right of Way Cut Permit Required <br />Installation Date -----V ------ <br />topubOc <br />QQ-O39JJ0 ______Date of Issue -/S~d-O <br />(TK6 Pipfi MaterialPipe Diameter 1. <br />// <br />□ System Development Charge <br />Ln C* 5S £Inspected By <br />hyjifxJ to attach prtoata <br />Public Wastewater Information <br />Index Page No.:■ 1----- Downstream<g-7 Segment No Contract No.Upstreom <br />TWO WORKING DAYS BEFORE YOU DIG. CALL UTILITY ONE-CALL SERVICE AT 1-800-332-2344 <br />T <br />N <br />! <br />KConnect +0 <br />oc.x. <br />t