HomeMy WebLinkAboutWORK ORDER - 04-00213 - 636 Autumn Ct - New SFR�Lwel hwo i l i
ACC# RT# PHONE EFFECTIVE DATE DATE
NAME Bt._ rt SERVICE ADDRESS
MAILING ADDRESS !_
OWNER J PHONE NO. OF PEOPLE
ADDRESS
EMPLOYER OR RELATIVE WORK PHONE _
COMMENTS
SS#
_
SIGNATURE
_
❑ IN
❑ READ
❑ RENTING
DEPOSIT AMOUNT
P. ON
❑ RE -READ
❑ BUYING
DATE PAID IN
❑ OUT
❑ CHECK LEAK
❑ SELLING
REFUND DATE
❑ OFF
❑ WTR.SWR ONLY
❑ OWNER
_
AMT. REFUNDED
❑ VACANT
❑ GR CONT #
❑ BL CONT. #
AMT. APP. BILL
W❑ T❑
METER SIZE
� GR RT#
BIN SIZE
NO. OF BINS ❑M ❑T [I L l
LOCATION
COMPLETED
BY
ISSUED BY
❑ COMPUTER FILE
APPLICATION FOR REXBURG CITY SERVICE
NAME
ADDRESS
PROPERTY OWNER
WATER SERVICE: Type Size
Water Connect......
_
Water Meter .......
_
Meter Box .........
f
Ring & Lid.........
f
Curb Stop .........
_
Setter ..............
S
Sewer Connect .....
_
TOTAL ............
In City Out of City
Storm Drains — $
APPROVED BY