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MINNEGASCO, INC. MAINTENANCE ORDER NO.
O MAIN O SERVICE PAV.CUT NO. LEAK RPT.NO.
DATE MUNIC. RESP.ACCT.NO.
FPC-or-E NO.
LOCATION:
NATURE OF WORK
FOREIGN STRUCTURES PRESS.CL. NEW SURFACE DISTURBED
Tele O 1 O A TAP -
0 Road Mix Bituminous 0 Dirt
Elec � 2 � C SIZE O Hot Mix Bituminous 0 Gravel
O 5 � E � Portland Cement Concrete O Oiled Earth
LighVTraf.Cable O 6 p F
� 8 ❑ K � Roadway 0 Blvd. � Walk 0 Alley
Other
Size Disturbed
PIPE LENGTH O Same Ft. Longer Ft.Shorter Ft.Abandoned
SERVICE TAP MEASUREMENT
DATESTARTED COMPLETED FOREMAN
TRUCK NO. TOWN NO. FOREMANS P.R.NO.
To the (City Engineer
(City Council
(Village Council
(Town Board
The u�dersigned hereby requests permission to perform the work
indicated above.
:g;��.,m,,,,�._; MINNEGASCO, INC.
', �
(Sr. Design Engine�
.,
To Minnegasco, Inc.
Permission is hereby granted Minnegasco, Inc. to perform the
work indicated above.
of
Date By
(Authorized Signature)
FORM 45A R3/78