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I <br />Public Works <br />Mointenonce______ <br />1820 Roosevelt Blvd. <br />EugenS, Oregon 97402 <br />(541) 682-4800 <br />Location of <br />Wastewater Connection <br />Property Information <br />Address :—_i------- <br />Map and Tax Lot — <br />Building Type: rfysFD □ Duplex □ Multi-Family □Commercial □ Industrial <br />1Z7I <br />Owner <br />Permit Information <br />Permit No. 19- D&Q ^Date of Issue <br />Pipe Materials. <br />□ System Development 1 <br />Inspected By -----/>• / • <br />to ay <br />^_________1Pipe Diameter. <br />Charge <br />Contractor/Plumber. <br />□ Right of Way Cut Permit Required <br />Installation Date -------- <br />andhto ptMkPtemMan grantad to attach prtvata <br />!