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OLD ADDRESS
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DATE TYPE
NATURE OF WORK
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OWNER
CONTRACTOR
V AtUATION
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METER(S) PERMIT
Date O — if 71
Name of Owner 7ry X C._ j'/ (c) s Co ti S 71.--
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Address of Owner /O 1, Spulh /A/L. Ave_
Meter Installed At A74,5--
' 3 //A' 7-1_ !/,
Meter (s) Size /.i o & "44 .2-.
'
Meter (s) Use P>tA t7 It w4t Sw
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sow / 9;1 1 y/l i V f-S
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(Diagram of Use)
Meter will be installed and used according to the above
information,
01.44r Agent
To Water Utility: Requirements have been met to purchase
and install meter (s) at the above address for size and use
indicated.
IL- iii4-_-. 2,-ci,---.'\_ - 0 iv.... .
P umbin g Inspector ector