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<br /> <br />.. -. -~ <br /> <br />~... ... '-'~ U,AJ...l>U.Y1 <br /> <br />" -'~''''-~-'''' - <br />. .". ~ -, . T ~ 't' .,. ~ ~ ~_. ..- .. ~ . . . <br />\,t. . ~i ,'(-...~j."":::'''.' <br />~ \ .,. \.' .. "", ,..:" . <br /> <br />....... .fQ..-;-..~ P. ~(9..'..... ........ <br />DATE . <br />LEGAL DESC~IPTION :............5.CA.6....rQ.....e.;::p.M.T.~.....^N..D...E::.)!.....W....6....5..1..... <br />....u..........,.,,:.~,....~......>..,..................... ...........fDLI.O'...P.:..r....~. TH.f;-:..S.......g..Q..7....~ ~,.~....F.r...... <br />';' ....,.f.. '. '7, ~ ..I I.. J '. c: S'''.'~ y'"'''' <br />...............:.... .....~................................................Q..r.:...,;v..WIJ.... ........Q....... .:on",r..,~.....os................~. <br /> <br />...... ..... ................ .......... .... ......... ...,.............. ....................:.... .~. ........ ............ ....:... ......... ..... .,... ....... ..._.. .~.S;.<:. <br /> .~. <br /> <br />.~.........................h.........................................,.........~.....................................................h................................................. <br /> '. <br /> <br />.. <br />, <br /> <br />OW~:ER ..l~.,...S....;.. :""DO(~..D..~+..~..l.(;;..~1.Z...:.t......,!.\. ADDRESS: .....2...:'I.a.Q..A~~.o......s~.. <br />, , . ' ,( : R.I ph ..e.atlt.. S'..."'1.. -;;;K.... 00 J . <br />2~~~g~~f:~~~T..~~~~~~~~~&~.Jo,!C'O.Q).......................................:....... <br /> <br />" ,'Uh"'b.L:..:' . ~ <br /> <br />...........~.~.us............................................... Sp.ecial Action: ..................................................................................... <br />. ' . 'PL.UMDER <br />", ; "" '. - . . A .:.L '.... II I .' ..' I ...L <br />WYE LOCATION .....~.....~.......'I........~~.b..~.....M~H....~....~.~. ..~.~&' <br />(DISTANCE FROM NEAREST DOWNSTREAM MANHOI.Iii:I _'. ,. ,..".. .".>.,'_ TJ._.. <br /> <br />" <br /> <br />j, <br />I' <br /> <br />Wye Connection" U1tO~ Sewer Main <br /> <br /> <br />4. '. _ ~ . ~ .~ <br />'REMARKS - MATERIAL IUSED <br /> <br />ITEM <br /> <br />Service Connection (outside Bldg;) <br /> <br />~b <br />~b. <br /> <br />Service Connection (within Bldg,) <br /> <br />Reuse of Existing Sewer Service ". (if applicable) <br /> <br />Street Resuffacing (if applicable) <br /> <br />Filling in of Septic Tank <br /> <br />I, <br /> <br />Filling in of Cesspool <br /> <br />Sketch <br /> <br />N. Arrow <br /> <br />Street t!t Property Line <br />Ties <br /> <br />InfonnatioJ:1 on Well. for serviCC Charge <br /> <br />~~, y: <br /> <br />~ <br /> <br />Well Size ,.............:...... in. <br /> <br />. . <br />WeUDeptb . . . . . . . . . . . . . . . . . . . . ft. <br />. . <br /> <br />)C!'\sutic_Water-Levd : . . . . .. :. . . . . . .ft. <br />:b Make of Pump .. .. .. .. . .. .. . . .. ... . <br />Model Number ................... <br />i . . <br />Serial Number .................... <br />" <br />~ Type of Pump . . . . . . . . . . . . . . . . . . . . <br /> <br /> <br />Motor H. P. . . . . . . . . . . . . . . . . . . . . . . <br /> <br />Addn'l Info. ..................... <br /> <br /> <br />.~~ <br /> <br /> <br />- <br /> <br />~ <br /> <br />.# <br />~ /e;;t? " <br /> <br />v <br /> <br />.. . RATED PUMP CAPACITY tal 40 p.li.i. .. GPM <br /> <br />...... ,,' "~-:\i <br />SIZE OF WATER METER (if no well) _G\~ <br /> <br />...:............:.........~ <br /> <br />Semce Recorded: ............, . :7. . . . . . . . . <br />