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" \ <br />�.........�.�i'�:�:�...:... V I�-. A G E � F R � S 6- ,' t L L E� �" �, ,: <br />R E C E 1 P T N U M D E R� ���. �OR SEWER SERVICE � CONNECTION ��.� .��� M �. �� <br />........ � -� � _ , y �--.�- _ . <br />. ........ .. m... ...... <br />� � � DATE . . . . . . . . f . J � . . � � � <br />� . . . � �...�/ �'"l�-G`G—Ya ..w ��.?. zC CG i..f�'3 �.�� .. '��'J.. �'..'�.�.�.......... <br />LEGAL DESCRIPTION ::..............................�....... .. ......... �.:.'.��. ` . ..... ��... C ... <br />..... ......... ......... ......... ......... ......... ...:..... ........ ......... ........- . ........(�i���,�. .�c�p�.:........... <br />.................. ........ ......:..................... J.... ....:... . .... . ...... .................. ......... . ....,. ................ <br />� � � . . � /`. �' "' . . . . ,�� � !.' .... . ...... . . . . . . . . . . . � . . . , . . . . . � . <br />OWNER ... �::..<..�.> �.....`�.:..`.�,: � �.:��„�.....,...... ADDRESS: ��...%......,���v... ��-.{..:?�,.;�..�.... <br />-� <br />,,- ' �'. <br />CONTRACT OR ................................................................................. ..........................:.........:.:..............:............................:....: <br />CHANGEOVER PERMIT Is O Is Not O Required , � <br />- <br />.........................:.....................................�... ................. Special Actian......:.... . . ...:.�. �.-�_.,�.c.c�a.�.a.c <br />- . . - � � . . . . . � P W M D E R . . . . . . . . . . . . . . . � ..��.. . -y�.�� � <br />WYE LOCATION .........................:.. �. .. . .... ..:.....................................:.....:........;....................... <br />.. . ................................................ . <br />� lDISTANCE FROM NEAREST DOWNSTREAM MAN1-IOLE7 <br />ITEM APPROVED DATE REMARKS - MATERIAL USED <br />Wye Connection into Sewer Main <br />Service Connection (ontside Bldg.) S <br />Service Connection (within Bldg.) <br />:euse of Existing Sewer Service (if appiicable ) <br />� <br />Street Resurfacing (if applicable) <br />Filiing in of Sepric Tank <br />Fitling in of Cesspool _,.. <br />Sketch Information on Well for Service Charge <br />N. Arrow . Well Size . . . . . . . . . . . . . . . . . . . . . in. <br />Streei F�3 Property Line Well De th <br />p ..... ............. fi. <br />Ties <br />Static Water Level . . . . . . . . . : . . . . . ft. <br />Make of Pump . . . . . . . . . . . . . . . . . . . . <br />� Model Number . . . .........:.. .. <br />. Serial Number . . . . . . . . . : . . . . . . . . . . <br />. TYPe of Pump . . . . . . . . . . . . . . . . . . <br />Motor H. P . . : : . . . . . . . . . . . . . . . . . . <br />Addn'] Info . .: . . . . . . . . . . . ...... .. <br />� RATED PUMP CAPACITY Ia/ 40'p.s.i. :. GPN! <br />SIZE OF WATER METER (if no well) <br />.... ........:....... ....r.--.�----_-._...__ ......, <br />Inu�d 8y.. r._.... <br />•-..-• .............................•--••-•--••----•----.......---- <br />�i <br />� - � - � Corviro R ocAf'fIP(� [ � : � - <br />. . . . . - - - - - ' - - - - - - - - ' ' - - <br />