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'-' "" TION FOR WATER AND SEWER SERVICES 717 7OFFICIAL RECEIPT —_ , <br /> DEPARTMENT OF WATER SUPPLY COUNTY OF HAWAII <br /> COUNTY OF HAWAII APPLICATION NO DEPARTMENT OF WATER SUPPLY <br /> DATE /� L <br /> TVIRONMENTAL MANAGEMENT, WASTEWATER DIVISION <br /> SERVICE 1 `u,.n1/4,11,0 D 3/ 1 <br /> NO <br /> RECEIVED 1 Served by Sewer: Yes No <br /> FROM `O Y �L _^ Service No.: 1/L 7,51/-"6.•,i.,:: (I Res x,o' Bus <br /> PAGE FROM TO AMOUNT No. of Units served by sewer <br /> METER RATE <br /> MI , 4 ,,,-4 <br /> INSTALLATION 9S DO Lot No. 1 <br /> FACILITIES <br /> RESERVE CHARGES <br /> aartment of Water Supply of the County of Hawai`i for water service, and the Department o <br /> f <br /> CREDIT DEPOSIT :• -i� the County of Hawai`i for sewer service, if applicable, at the above location. Pending approval, <br /> SERVICES i 411 <br /> I <br /> :e(s), the undersigned agrees to pay all charges incurred upon such location for such service(s) <br /> METER <br /> �° CD <br /> ;s, provisions, and policies prescribed by the Department of Water Supply and the Water Board <br /> LABOR&MATERIAL t,. �� c '' <br /> --• nental Management of the County of Hawai i, and the State and County of Hawai i, relating to <br /> �Q' understands that they will be billed by the Department of Water Supply for water service, and if <br /> Division of the Department of Environmental Management for sewer service. <br /> 6� ' 2 ,r JNLY ACCOUNT INFORMATION <br /> 9c'.SZble . <br /> AAplica gent: . /,! for L-VI-e ... <br /> Billing Address: '~ !"1 , i '.`ate ,X 67-73.°7-37-- <br /> CASH 0 M.O. 0 TOTAL i,9 DD t/) 7r// i. 7d0 <br /> CHECK pis T 4�„{, <br /> ���'L <br /> OFFICE 0 MAIL 0 ID#: i 0 0 7,)/ /10 HVL---- 1/61l;2"e''- <br /> ' ' <br /> 2 8 2 6 6 2 RECEIVED BY `W Phone: (H) �,.� ' i^ (B) ¶ 9-'1 alp (C) <br /> mm___,_____ — Signature: ! *'l► Date: • o <br /> LIMITED TO GALLONS PER DAY ( ) UNIT(S) <br /> DWS Cust Svc Rep: _9:2/ <br /> The County of Hawaii is an equal opportunity provider and employer. Rev 5/11 <br /> CUSTOMER <br />