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i . <br />j" <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 ____j_____ <br />Map and Tax Lot — <br />Building Type: j^TSFD □ Duplex □ Multi-Family □ Commercial □ Industrial <br />jo A vc <br />rroaenOwner <br />Permit Information <br />Permit No.\-35-30ao- 0033^-01 <br />rnntrnrtnr/PlumhRr ^ <br />□ Right of Way Cut Permit Required <br />Installation Date ____^ ^ o[ O___ <br />Date of Issue <br />Pipe Material SclK-HQ pjpe Diameter H" <br />□ System Development Charge <br />Inspected By <br />connmMoa to puttie mmr h ccnfommonc* to Oty ttondanit end iptcilkationa.Ptrm/nion grant*! to attodi privatt <br />Public Wastewater Information <br />Index Page No—^LJ. <br />Inspected By _ <br />Upstreom DownatreomSegment No.Contract No. <br />TWO WORKING DAYS BEFORE YOU DIG, CALL UTILITY ONE-CALL SERVICE AT 1-800-332-2344 <br />O <br />4331 VC, <br />d% <br />I <br />15 <br />\ <br />r <br />ry-C,*l <br />iL