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FIRE HYDRANT USE PERMIT
NONTRADITIONAL WATER CUSTOMERS
35NorthlstEast Noah.phethean@rexburg.org Phone: 208.372-2136
Rexburg, ID 83440 www.rexburg.org Fax: 877.397.3917
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Date Issued_ Meter # eeeeeFH I`
p Permit# 2Q�DbbZr
Business name: r/f7 / 4rK �(_ Phone #
Picked up by CT_ cT 'It Phone #
Address: 41 is .Z� NDS K
Year Issued: J.VO~U
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Hose Number:
Deposit amt: (Receipt Code= WDEP) with credit cards charge an additional 3.5% (Receipt Code= MISCG)
$1,600 Large Capacity Water Meter j/ Deposit retained? ✓ or refunded?
( date)
$ 600 Small Capacity Water Meter
CONDITIONS OF PERMIT:
In order to prevent possible contamination from backflow of the Rexburg city water system, any persons or entity
desiring to obtain water from a city fire hydrant must comply with the following:
1. Obtain a written permit from Rexburg City Hall, 35 Nil East, before attempting to take any water.
2. Take water only from the one fire hydrant designated by the city water department.
3. Checkout the backflow and metering device from the city water dept. to be attached to the fire hydrant
agreed upon by the user and the city water deptment.
4. As indicated above a deposit will be required on any metering device. Any damage to or loss of the device
will be paid for by the user. After any use, repair, or replacement charges are deducted ,the balance of the
deposit will be refunded to the user. (City water dept. will conduct a final inspection.)
5. The fee for any water obtained through the metering device is as follows:
Fee: 1 —1,000 gallons $10.00 Each 1,000 gallons thereafter : $5.00
6. A $50.00 maintenance fee for 1" and $75.00 maintenance fee for 2" will be assessed each year for
maintenance on the meter.
7. The meter needs to be returned by 12/1 for testing calibrations. A meter can be reissued the same day per
request if needed.
Any person or entity not complying with this policy shall be assessed a penalty charge of $400 in addition
to the normal charge for the water taken.
Signa re of Appltcant
REFUND TO:
METER OK: YES OUT READ
NO IN READ
GAL. USED _
READ DATE _
METER RE -ISSUED?
Issued by:� //
CHARGES:
_ METER MAINT
_ 0- 1000 GAL
_ ADDITIONAL WATER
YES / NO REPAIRS -PARTS
TOTAL
Received by:
75_ 00 —
10.00
outlined be� „
ing these IL , (t,%np
al's set of (
nts, it will a I
and childrer A'+�
proposal who /�/.&
�fJ _Y,
nity Water Systems It
Line (LSL) removal b(
III start removing LSL s
Ins will begin replacemc
Int sampling will idenP
this with levels above h
improved sampling pr(
:ement.
0 ppb systems will me
ed monitoring at >10 I
mples must be taken
ton sampling proced,
tg faucet aerators of
replace the entire
lead Service line re
pystems must repla
their customer-ov
longer be able 1
�
ent rule allows S
m an individual
rule remo
R ItsNn slEosr Now,
Date Issued SID Noah henei.o"tro+t
Business name:
Picked up by
Address: (p1
eK�� �••iC
Deposit amt:
$1,600 Lar (Receipt Co r
$
600S
Large CapacitY Wade= WDEP)
mail Capacity Water ter Meter
^ oNderitoNS OF PERMIT: Meter
desiring prevent Possible
S to obtain Ie contami
io
1' Obtain a writtener fPer roma City fire thydrant
2.
ex urg
3. only from water thero a fire hydn
4.
5.
6.
7.
Any Person orentity no
to the normal charge for the Plying
with th
REFUND TO:
METER OK: YES
NOS OUT READ -�
IN READ
GAL USED
READ DATE —_
METER
UED�
Issued by;
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