Burch Lot 3-WO 951208 WATER UTILITIES DMSION
Employee Making Inspection:--~zx r~ h ')~rrc'~
Name of Development: ~' I ,~ ~ ~ ~c~,-~ f~
Contractor:
Set Up Account For:
Billing Address:
Date:
METER
Meter Type:
Model: .~){/V~ ~/~
Size:
Vault: Box:
~pection Co~en~: ~ ~
Backflow Device (If Applicable)
Type: '
C
Model:
Size: (~
Vault:
Inspection Comments:
Box: . r ~z x,/wl.~ t ~nal Numner. .
Has Backflow Prevention Device been tested on site in its actual setting: Yes
If so attach test form or forms.
(Circle One)
NO
Disk 4 Forms (inspect)