257638 site plan.pdfCOMMA CSG Locate#: 9-1 CSG Drop Bury#: Date,O ) _erode: 14& BUry Drop Form
Customer Name: I ponAq, Phone# :j
Address; �,%qo_L 9-5th 1W City rod" t 5 Zip: ggo,a&cross Street:
❑Service l iecting ❑out of Service MendingInstall ❑Tesmped Tech# Tech CeIL• L}�-3f�8'a3 i.5
Priority Level: ❑1-Commercial 2-New Cust/Svc Drop Impaired /Can't Temp ❑3-Svc Drop impaired/can Temp
permit Required., Y� N❑ Back YardEasement: YNC�I
Type of Bury: STH Footage ROW Footage planting Sir ip: Y[ N[ sprinkler System: Y N�
Sidewalk Y[]
Sore septic Field:
Driveway Bore sidewalk: YEN
YX NQ
Road Edge. Y N Drain Pipe:
Landscape Bare EI
YE] N Private Water: Y
Curb:
Road )Tore
f Hard Surface Total: 30 Private Wiring: Y[j No
O �'
soft Surface
Total Bur +- What Kind?
G2c. c o •11 Total:loZD' Total: I Y o71 `
`I
Customer Horne For Bury: Y Nin Call Customer First: Y N❑ best #For Customer: o2`� a�
Comments (3 --1 I1 OGq
'll bu c r 0ex
CUSTOMER CONTACTED AND REVIEWED ROUTING OF iVFW DROP Y NOT HOME, LEFT DOOR TAG Y[]
Tieing the owner of the above property, I hereby give my permission to Cnmcast, ortheir duly authorized iepresentat€ve
to bury a service line on my property, Property Owner's Signature:
._._�.T — �—�...tasa� msss,+_r_.{.y•Ft.:t_W,ari.�!�rt�a'-:'9rS.w.`-']YiK!'{iT+,1-it'h?.'�i.�J'�L