Section 1 of 1 in this document
Temporary Backflow Device Request
Builder Company Name
*
Email
*
Phone Number
*
Full Address
Street Address
*
City
*
State
*
Zip
*
# of Units
*
Subdivision
*
Phase #
*
Lot #
*
Permit #
*
Type of Service
Potable
Reclaimed
Please confirm the following:
Lot is clearly marked with a lot number or building permit is posted
Meter box and lid are visible and accessible
Meter resetter inside box is not bent or altered
Meter service has water
Requester's Signature
Requester's Signature
First Name
Last Name
Email
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