Enter Site Characteristics Below

Tick Appropriate Boxes:

Vacant Land
□ Domestic □ Charitable Organization □
(Domestic I Commercial) (No. of Bldgs & Connections) (State REG No.)

Agricultural Land
□ Commercial
□ Multiple Apartment Bldg
□
(Type of Business) {State No of Apartments)

Dilapidated Building
□ Building under construction □ Cottage □
Sewer
□ w.s.c □ Swimming Pool □
Disc. Service:
□ P.S.P. □ Single Yard Tap □
Meter Read: Meter Read Date: Meter Number:

Enter Premise Description and Land Marks:

This property contains a two story concrete house painted Yellow.

Property is fenced by a Yellow concrete wall and Black gate.
One unmetered water service connection services this property. Supply is internal

A3 Water & Sewerage rates are applicable and correctly charged to the account

Enter DRO
Information
Below

REVENUE OFFICE FINDINGS: D.R.O. I CITY HALL OFFICE LOCATION: POS

CURRENT L. & B. NO. : Previous L. & B.NO. :

Present Land Owner:

Previous Land Owner:

Present Building Owner:

Previous Building Owner:

Premise Address:

Boundaries:

i:::: N:

W: S:
 Acreage: I No. Rooms: No. Bldgs: 1 A.T.V.: 10,840

Effective Date: I Date Entered on Rolls: Return No.

Enter Field Officer’s Recommendations:

Issue Clearance Charitable

Organization
Multiple Clearances / Bills Provisional Assm’t form must be signed
by Customer

Create New Account/s Meter Feasibility

Class Change Refer to Systems \ Water Loss

ATV Change Update Account

Information

Field Officer’s Recommendations Description:

No updates necessary
Issue Clearance Certificate subject to payments of all rates and charges

Field Officer’s Name (Block Letters): N.ENILE

Field Officer’s Signature: Date:

Coordinator I Administrator Recommendations:

Coordinator / Administrator Name ( Block Letters):

Coordinator / Administrator Signature:

RECOMMENDS TIONS APPROVED RECOMMENDSTIONS NOT APPROVED