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<br />.' .:'.~_.~~ ~ ~-' '~Vlr..'~AGE OF ROSE' j'ILLE <br />.....;;!!.....I~I:...L........ . <br /> <br />RECEIPT NUME!ER . . . <br /> <br /> <br />_.__~.l~.~ . <br /> <br />.....Z::?......~.I!~..j!y....~.......~f..~.....}t(I}I.'....._hG.....~."-.:.t:.:~.~?~~f............... <br /> <br />OWNER ..j::::::::2:(2~~.:.:.:.:.:.:::~~~~~~.j~~~.~..:.:..:.:.:.: <br />CONTRACTO~R' . ~ AJ.. ....'~..~..........(~?~)............................................................................. <br />)R.~.... ..... ~(urR . ;J <br />~~U'~]:~.~l4V~)~...~ot ~pe::~:::~.................._......u...................................... <br />WYE LOCA;IO;~..................:.......!..:.~~........:J;~...~......~...~~...~.k:/!J..II...~.................... <br /> <br />(DISTANCE FROM NEAREST DOWNSTREAM ANHO EI <br /> <br />5V .........~. <br /> <br />Wye Connection into Sewer Main <br /> <br /> <br />REMARKS - MATERIAL USED <br /> <br />ITEM <br /> <br />Service Connection (outside Bldg.) <br /> <br />/;//(~'- / , <br /> <br />r <br /> <br />Service Connection (within Bldg.) <br /> <br />Reuse of Existing Sewer Service (if applicable ) <br /> <br />Street Resurfacing (if applicable) <br /> <br />Filling in of Septic Tank <br /> <br />Filling in of Cesspool <br /> <br />Sketch <br />N. Arrow <br />Street f!1 Property Line <br />Ties <br /> <br />~)at?l;Z::C-~ <br /> <br />Information on Well for Service Charge <br /> <br />.,. ~'_ ,I <br />i ;". .' <br /> <br />Well Size ..................... in. <br />Well Depth. . . . . . . . . . . . . . . . . . . . ft. <br />Static Water Level ~ . . . . . . . . . . . . . . ft. \ <br />. Make of P\unp . . . . . . . . . . . . . .) . . . . . <br />. . . <br /> <br />Model Number ... ~ . . . . . f~. . . . . . . <br />., (' <br />Serial Number IY)";;;" '. ~. . . -+ e. . . . . <br />Type of Pump II. \.. .. t,J",.. .. .. .. <br />Motor H. P. . . . . . . . . . . . . . . . . . . . . . . <br />Addn.l Info. ..................... <br /> <br />1,._._ <br /> <br />RATED PUMP CAPACITY /a/ 40 p.s.i. . . GPM <br /> <br />SI~.OF.~A~.~~ .Of .~.w~>f:_ <br /> <br /> <br />Service Recorded:. . . . . . . . . . . . . ~I E .J). .~. <br /> <br />houed 8y.._.._~J.iLm................. // <br /> <br />. I <br />