HomeMy WebLinkAboutHYDRANT PERMIT 2 - 21-00249 - Headwaters FHM 11LMIIO AgeMfS 7F
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Deposit amt: (F
$1,800-2' Wag
$ Wo - 1' Wat.
CONDITIONS or p
In order to prevem
des.nne to obtain v
1. Obtain a We
2. Take water,
3. Check our th
agreed upon
4- As 1nd.cated a
WO be paid fo,
deposit will be
5 rhe tee for any
Fee: 1
6 A $so 00 malntf
manttenance on
The meter needs
request N needel
3W G1r.%) Any Person or entity nc
4OW460000 she, to the nOrmai charge fc
W
asreGI V
& REFUND TO:
st METER OK: YES
IL NO
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Phone # 313 — 471i_
Address: 9D0 tjJ. y,
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Ae&V r4 � 4y� Year Issued:
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?
$ 800 - r Water Meter(date)
CONDITIONS OF PERMIT:
In order to prevent possible contamination from backflow of the Revhl., ty persons or entity
desiring to obtain water from a city fire hydrant m•,••
I. Obtain a written permit from Rexbu any water
2. Take water only from the one fire by
3. Checkout the backflow and metenn` �l the fire hydrant
agreed upon by the user and the city
4. As indicated above a deposit will be re f. �y. �Y JL oss of the device
will be paid for by the user After any u [!� he balance of the
deposit will be refunded to the user. (Cr
5 The fee for any water obtained through -
Fee: 1 - 1,000 gallons $10.00 _ p
6. A $50.00 maintenance fee for 1" and $7. r $�V a ear for
maintenance on the meter.
7 The meter needs to be returned by 12/1 far D A l same day per
request if needed. ��
Any person or entity not complying with this po _ iessed a penalty charge of $400 to addition
to the normal charge for the water take. --
Signature of Applicant
REFUND TO:
METER OK: YES OUT READ I SSJ CHARGES:
NO IN READ METER MAINT 75.00
GAL USED 0- 1000 GAL 10.00
READ HATE ADDITIONAL WATER
METER RE -ISSUED? YES / NO REPAIRS -PARTS
TOT j�
Issued by:
Received by: `�-
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