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Acct. No <br />CITY OF EVERM—Water Dept. <br />Applicatio5/N: <br />Date ..... ....................... <br />Jnstall...,,, ln�cwater s 'cepi e <br />.... ........... <br />Owne <br />Address.... <br />... ... . .. ........ _...................... .... <br />Lot......... �W'1-1-1*— .............................. Block No.._--- <br />Contractor <br />Remarks <br />ShopRemarks......._.._ ......................_.._.._ ........ ........... <br />.......................... . .......................... . ...... ............... ............... ....... ........ .......... <br />WorkCompleted ........................................................... .................... F . o . re <br />man <br />