CVWD - Stub Out Staking Form 192 - 2023-12-07COACHELLA VALLEY WATER DISTRICT
TRACT NO.
DEVELOPER:
Name of Firm
Representative
Mailing Address
Telephone No. ( )
ENGINEER:
Name of Firm
Representative's Office
Mailing Address
Telephone No. ( )
Stub -out Connection Staking Information Form
Known as
I prefer that you contact the individual listed above to arrange for staking of the stub-out(s) location.
Developer
Li
Date
NOTE FOR THE DEVELOPER
Engineer
Digitally signed by Ubaldo Ayon
�_ L • Jr
� Date: 2023.12.07 09:23:04
-08,00,
This form and the deposit for stub -out connection(s) must be either mailed or delivered to the district.
Mail or hand delivery Hand delivery only
Coachella Valley Water District
Attention: Development Services Supervisor
Post Office Box 1058
Coachella, California 92236
Coachella Valley Water District
Attention: Development Services Supervisor
75-525 Hovley Lane East
Palm Desert, California 92211
CVWD-192
(Rev. 9/06)