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OLD ADDRESS
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DATE TYPE NATURE OF WORK
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OWNER
CONTRACTOR
VALUATION
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METER(S) PERMIT
Date
Name of Owner % ✓ ,lG. . ; .
Address of Owner
Meter Installed At
-
Meter (s) Size
Meter (s) Use
(Diagram of Use)
Meter will be installed and used according to the above
information,
Owner or Agent
To Water Utility: Requirements have been met to purchase
and install meter (s) at the above address for size and use
indicated. i
z„./,ter
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