Quattro - 18780 - Park One 3rd Addition - Lot 2, Block 2 (2) SEWER, WATER, O%, OMB'INATIO ERVICE FORM' (CIRCLE ONE)
ipalitY ~_~~.~ Service No.
Project No. ~-/~- Sheet No. II/
Lot ~ Block ~ Parcel No.
Addition '~ 0~- TH [~ ~l~
House No.
SEWER:.
Downstream Manhole No. _~_ Sta. at P.L. from Downstream Manhole
Elevation at C.L.'of Sewer Main 7DZ7 Top foundation Elevation
Depth of Basement Depth of Clean-out Clean-out Elevi
Distance from Sewer Main to Clean-out
% of Grade for Service to be installed
(If minimum grade service) --
Length, size and type of service
pipe ~__.a'/~-'~l/d.. Depth at P.L. ~6)~,~.
WATER:
Downstream Manhole No.
Length, size and type of service pipe /w/ Depth at P.L.
eck if riser is not installed to within 5' of surface at P.L.
Denotes sewer service end
Denotes water service end --
6 Sra. at P.L. from Downstream Manhole
'
(indicate North by arrowhead) ~*', ':-....'.
. ' -
~ ............ .-- . .' .-~.," ~ .... '. ~ ~' ..'
)ntractor ~ ~~ C~")~O.b--'/~ Foreman ~/~'
'.ed by ~. ~O~~. Date
Location and depth of services certified bY .~ Date