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?PL PION FOR WATER AND SEWER SERVICES f 1. i i <br /> COUNTY OF HAWAII <br /> DEPARTMENT OF WATER SUPPLY <br /> DEPARTMENT OF ENVIRONMENTAL MANAGEMENT, WASTEWATER DIVISION <br /> Served bySewer: Yes No <br /> r L" ;. . -7 Bus <br /> Date of Application: Service No.: 'l r��'` I 1'.` Res <br /> No. of Units served by sewer <br /> LOCATION/ADDRESS: 'r ` ' <br /> TAX MAP KEY: : - '`_. r` r , Lot No. /--#') <br /> The undersigned applicant hereby applies to the Department of Water Supply of the County of Hawai`i for water service, and the Department of <br /> Environmental Management, Wastewater Division, of the County of Hawai`i for sewer service, if applicable, at the above location. Pending approval, <br /> and in consideration of commencement of such service(s), the undersigned agrees to pay all charges incurred upon such location for such service(s) <br /> and to abide by all rules, regulations, ordinances, codes, provisions, and policies prescribed by the Department of Water Supply and the Water Board <br /> of the County of Hawai`i, the Department of Environmental Management of the County of Hawai`i, and the State and County of Hawai`i, relating to <br /> water and sewer services and rates. The undersigned understands that they will be billed by the Department of Water Supply for water service, and if <br /> applicable, will be billed separately by the Wastewater Division of the Department of Environmental Management for sewer service. <br /> FOR DWS DEPARTMENTAL USE ONLY ACCOUNT INFORMATION , <br /> Category Code: 70%: P f/ � <br /> Purpose: System Code: Applicant/Agent: f " r> �; <br /> Flat/Estimated Fees: $ -.,�='t , __Rec # 1'L iLU,i/ 1?_ w .O.9 UpC 1'c , 5*-" 0 --, <br /> Fee Description: __ _ _ Billing Address: �.►�anr ♦.I�' i MLe., <br /> Facilities Charge $ _ Rec # �,, <br /> Credit Deposit $ — Rec <br /> . Rec#�� _ r'/ '"f L -7°' ' <br /> Work Order No.: Size: "f 71 ? ' / , <br /> Meter No./AMR No.: /0: 2! _ / ID #: / 0 0 r?)/ f-70 h!Dl_ I/61 <br /> 7/ 3).e'1,-.1 <br /> Reading When Installed: Date: <br /> Elevation Agreement: _ _Backflow Preventer: Phone: (H) r41 w '34c (B) .l 55- OD (C) <br /> Out-of-Bound: Date Service Started: (T -""--., <br /> Remarks: Signature: 1 (' , Date: <br /> LIMITED TO )GALLONS PER DAY ( )UNIT(S) <br /> _ __ DWS Cust Svc Rep: .9'"?) _ <br /> The County of Hawai`i is an equal opportunity provider and employer. Rev 5/11 <br /> CUSTOMER <br />