WATER SERVICE AS-BUILT SKETCH ACCNT # (to be ACCURATELY completed by owner or owners representative before water will be turned on.) Sketch shall include: distance of water service from water main to curb stop; distance from curb stop to building; ties to corporation and curb stop; depth of service; location of all underground utilities in relationship to water service; and ties from permanent structures (ie; buildings, manholes, catch basins, etc.) DATE INSTALLED:

INSTALLED BY:

SIZE & TYPE OF SERVICE MATERIAL: OWNER OF PROPERTY: PROPERTY ADDRESS: MAILING ADDRESS:

I hereby attest that the above information above is true and accurate, and that all work was completed as prescribed in the Rules and Regulations of the Shirley Water District.

Authorized signature of installer

Date