2. Town of Shoshoni
   P.O. Box 267
   Shoshoni, WY 82649
   Phone: 307-876-2515
   Fax: 307-876-2202
   
4. Name of Property Owner*
5. Phone Number*
7. Mailing Address*
9. City*
10. State*
11. Zip*
13. Physical Address of Proposed TAP*
15. City*
16. State*
17. Zip*
19. Legal Description of Proposed TAP
21. Addition*
23. Block*
25. Lot*
27. Requested TAP size*

    1. 3/4" (Standard)
    2. Larger sizes are at customer's expense
    3. Pit Tap
29. Depth*
31. Kind & Size of Service Line*
33. Electronic Signature of Property Owner*
34. Date*
    Date
38. For Office Use Only
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

* indicates a required field