Address: _______________________________________________________________
City: _______________________________________ State: ________________
Zip Code: ____________________________________ Phone: ________________
WATER:
___ ¾” Water Tap Cost: _____________________
___ 1” Water Tap Cost: _____________________
___ 2” Water Tap Cost: _____________________
___ 3” Water Tap Cost: _____________________
___ 4” Water Tap Cost: _____________________
___ ______________________ Cost: _____________________
Permit #: ________________ TOTAL COST: _____________________
SANITARY SEWER (BASED ON WATER LINE TO BUILDING):
___ Sewer Tap – Water Tap Size: ______ Cost: ______________________
___ ______________________ Cost: ______________________
Permit #: _________________ TOTAL COST: _____________________
STORM SEWER (BASED ON WATER LINE TO BUILDING):
___ Sewer Tap – Water Tap Size:______ Cost: _____________________
___ ______________________ Cost: _____________________
Total Amount Due: ________________________
(Please pay Total Amount Due at Reliable Plumbing and Heating. Amount is due prior to making any taps.)
Approved by:_____________________________________ Date: ________________
Date Paid:___________________ Amount Paid:_________________________
Faxed to: _________________________________ Date: _________________
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