HomeMy WebLinkAboutHYDRANT PERMIT 2 - 21-00575 - HeadWaters FHM 155 F eceipt Code= MISCGI
rd7 date)
tYs1em, any Persons or entity
Ina to take anY water
trnent,/ire hVclrant
rrac hod to the
,Mae to or lose device
balance nce afthe
leduc ted ,the
rtlon.)
,ssed each year for
elssued
he same day Per
Irge of $400 in addition
35 North I St East
Rexburg, ID 83440
Date
FIRE HYDRANT USE PERMIT
NONTRADITIONAL WATER CUSTOMERS
Noah .phetheanOtexburg.org Phone: 208.372.2136
www,rexburg.org Fox: 877.397.39/7
CITY OP
�URG
Amr/kai /vnrdv Cinrrnrur„ry
VA Meter # � Hose Number:_
/ Permit#_ 2/-pDI`,xd"
Business name: ..� UA �-t �.+t Phone #
Picked up by ,ion $2 Phone # 2D9ft 3/3 —f Zip
Address: _ 9400 /V. Y l =do- ALCA4y,
—� %� �3yy�' Year Issued: _w
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 - 1" Water Meter V ( 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 1`t 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 take
Signature of Applicant
REFUND TO: CHARGES:
METER OK: YES OUT READ _ a(
NO IN READ �,�R METER MAINT 75.00
GAL, USED 0-1000 GAL. 10.00
READ DATE ADDITIONAL W ATER
METER RE -ISSUED? YES/ Ol REPAIRS -PARTS
t/� TOTAL
Issued by:`" '
Received by: L��S
avhm.4w \It`tk,
kaww% %ftvnw.W
*"04 tihtrr
""k0iitsr • l u ,
cAsa
CaNna.r y
MY KnWay.,a
"'^atnvw 4r „
wtKtrq Ot wAh a
oC"«egla clutn
Any Y on[
402 HOL1'
The Gty v
New Y ea
Martin i.
Preelde
Memo
.1wrnett
lndev