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35 North ist East
Rexburg, ID 63440
Date Issued
_
Business name:
Picked up by
FIRE HYDRANT USE PERMIT
NONTRADITIONAL WATER CUSTOMERS
Nooh, phetheonOrexburg.org
www,rexburg.org
L•BIN
Address: 2K60S.
8 3.44
Phone: 208.372-2136
Fax: 877.397.3917
Meter # Z
Permit #
Phone #
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REXB
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Hose Number:_�-
43A
Phone #cul 35-1- 4&77
Year Issued: 2D2�
Deposit amt: (Receipt Code= WDEP) with credit cards charge an additional 3.5% (Receipt Code= MISCG)
$1,800 - 2" Water Meter Deposit retained? Z. or refunded?
$ 800 - 1" Water Meter ( date)
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 N 1s` 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
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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.
Signature of Applicant
REFUND TO:
METER OK: YES
NO
OUT READ
IN READ
GAL, USED
READ DATE
CHARGES:
METER MAINT
0- 1000 GAL
ADDITIONAL WATER
METER RE -ISSUED? YES / NO REPAIRS -PARTS
TOTAL
Issued by: c2z Received by:
75.00
10.00
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