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bbSSO <br />i- <br />Public Works <br />Maintenance <br />1820 Roosevelt Blvd. <br />Eugend, Oregon 97402 <br />(541) 682-4800 <br />Location of <br />Wastewater Connection <br />Property Information <br />Address —:—:— <br />Map and Tax Lot <br />Building Type: <br />i/atY) A\JC.[531 s' <br />Bray] 4 firodenOwner <br />FD □ Duplex □ Multi-Family □ Commercial □ Industrial <br />Permit Information <br />Permit No. <br />Contractor/Plumber—ftfayrt fc-YC'- <br />□ Right of Way Cut Permit Required <br />Installation Date --------- <br />PwmMon oranM to attach pchata <br />/3-/9/9 <br />Sch. Pipe Diameter.^_ <br />Date of Issue <br />Pipe Material- <br />□ System Development Charge <br />Let Ca- sre.Inspected By <br />h ccnformnonc* to City atandanto and wpadlhatton*.conn^tha to public <br />Public Wastewater Information <br />Index Page No.,Upstream UoWrtsVeaminSegment No.Contract No. <br />TWO WORKING DAYS BEFORE YOU DIG. CALL UTILITY ONE-CALL SERMCE AT 1-800-332-23+4 <br />T' <br />N <br />/ <br />, t