Date : ________________

AUTHORIZATION

IN CONNECTION WITH THE APPLICATION FOR WATER SERVICE INSTALLATION OF

APPLICANT / NAME : _________________________________

ADDRESS : _________________________________

IS HEREBY GRANTED / PERMITTED TO :

_________ DRILL THE FENCE FOR THE WATER SERVICE CONNECTION TAPPING TO INSIDE
CONNECTION INSTALLATION.

_________ CONDUCT PIPELAYING ACTIVITIES CROSSROAD / NEIGHBOR’S PROPERTY

ADJACENT
FROM__________________________TO _____________________________
FOR TAPPING FOR INSIDE CONNECTION INSTALLATION.

LUMINA DEVELOPER / AUTHORIZED REPRESENTATIVE

(Signature over printed name)

NAME OF NEIGHBOR