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Application No—& .. � <br />Book No. '4 <br />By. .................... <br />4- <br />Lot No ........ ......................................................... <br />Block No -1 .....3 <br />.. ............. .................. <br />Addition . .................................................................. .. <br />A <br />Distance A .................... FL.......................... In. k" <br />0 <br />B.... !�.� .................. Ft ........ ...... ......... In. <br />E <br />C ...... ......... Ft.......................... In. <br />0 <br />D ........................ ...... rt ...................... ... In. <br />Size of Connection....___.....,,,.. . ........ <br />Date of Installation ...................... <br />Property <br />C ...... ........... X .................. D Line <br />Water <br />Name of Street <br />A <br />Stop f7i Cock <br />e. I, Line <br />Main <br />