HomeMy WebLinkAboutCITY SERVICE APP - 04-00323 - 54 Valley View Dr - New SFRAPPLICATION FOR REXBURG CITY SERVICE
NAME
ADDRESS
WATER SERVICE: Type J -- Size 2 � l
Water Connect...... $
Water Meter .......
$
Meter Box .........
$
Ring & Lid.........
$
Curb Stop .........
$
Seller ..............
$
Sewer Connect .....
$
TOTAL ............$
In City. Out of City
Storm Drains — $
APPROVED BY
WORK ORDER
ACC# RT# PHONE EFFECTIVE DATE
NAME. SERVICE ADDRESS
MAILING ADDRESS V
OWNER PHONE
ADDRESS
DATE
NO. OF PEOPLE
EMPLOYER OR RELATIVE WORK PHONE
COMMENTS
SS#
SIGNATURE
❑ IN
❑ READ
❑ RENTING
❑ ON
❑ RE -READ
❑ BUYING
OUT
❑ CHECK LEAK
❑ SELLING
❑ OFF
❑ WTR.SWR ONLY
❑ OWNER
F_IVACANT
❑ GR CONT #
❑ BL CONT #
METER SIZE _
LOCATION
COMPLETED BY
DEPOSIT AMOUNT
DATE PAID IN
REFUND DATE
AMT REFUNDED_
AMT. APP. BILL
GR RT# BIN SIZE NO. OF BINS❑M T ❑W ❑T F S❑
ISSUED BY
❑ COMPUTER RLE