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bbmv-Kf-■ <br />5 <br />i <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 -------:--------- <br />Map and Tax Lot___ <br />Building Type: ^jfSFD <br />15~1I A\J£- <br />Rrvcp l a ) if r fap rl-—------------------------------Owner <br />□ Duplex □ Multi-Family □ Commercial □ Industrial <br />Permit Information <br />Permit No. <ol O ~~ C~)C~) / ^ ~1 <br />Contractor/Plumber f A plg.'t'O LT <br />□ Right of Way Cut Permit Required <br />Installation Date —~ ^_____ <br />a-G-ao >tDate of Issue - - <br />Pipe Material 'Sr.L|Lf^ Pipe Diameter__1 <br />□ System Development Charge <br />Inspected By - <br />h conformrtonc* to CKv rtandardt and BpocMcaifon*.Pwmlnhn grantod to attach prhoto connacdoa to outdo <br />! <br />i