HomeMy WebLinkAboutHYDRANT PERMIT - 21-00249 - Headwaters FHM 11'lass detail page.
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RANT USE PERMIT
FIRE HYD ar%"''
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NONTRADITIONAL WATER CUSTOMERS p >0 17 r. V i2BG _,ter•
Ann•d•nS lr+mdv Cummumly ' /�
35North tstEast Noph.phelheanGrexburg.org Phone: 208.372-2136
www,rexbur or Fax: 877.397.3917 •
Rexburg, ID 83440 9 9
Hose Number:
Date Issued c� Meter# -sL ���, __-
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Permit #_aL � S24W`N O
Business name: h J UlAjr--c I bc%dt Phone # g�dg2
Phone ZDV -313. g?lU Idg1a M ---1 r $
Picked up by 400 P\ ��/1 / N N o 0 o N
Address: Y(t7SIC>nB
Ae„Year Issued:-
�l 1
Deposit amt: (Receipt Code= WDEP) with credit cards charge an additional 3.5% (Receipt Code= MISCG)
$1,800 - 2" Water Meter Deposit retained? or refunded? Bldg 19 - N
$ 800 - 1" Water Meter ( date) s
1N MO O
CONDITIONS OF PERMIT:
In order to prevent possible contamination from backflow of the Rexburg city water system, any persons or entity
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desiring to obtain water from a city fire hydrant must comply with the following: �JM'u I
1. Obtain a written permit from Rexburg City Hall, 35 N 1" 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 1211 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 take .
Signature of Annlir.Ant
REFUND TO:
METER OK: YES OUT READ �§
NO IN READ
GAL. USED _
READ DATE
METER RE -ISSUED?
Issued by:
YES / NO
CHARGES:
METER MAINT
0- 1000 GAL
ADDITIONAL WATER
REPAIRS -PARTS
TOTAL
Received by:
75.00
10.00
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