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35 North Ist East
Rexburg. ID 83440
11141211
FIRE HYDRANT USE PERMIT
NONTRADITIONAL WATER CUSTOMERS
Nooh.phelheondrexburg.ag Phone: 208.372-2136
www.rexburg.org Fax: 877.397.3917
Date Issued Meter q
(i 1 Permit# dl
Business name: l rx t fa o6jTo C • Phone #
Picked ul
Address:
Hose Number:
31Lv
Phone # 6 / - I Zt / i/ %
lo�a�I�,: tif'r,� Pte.•.- S�� ���
Year Issued: Z02-(
Deposit amt: (Receipt Code= WDEP) with credit cards charge an additional 3.5% (Receipt Code= Mill
$1,800 - 2" Water Meter �_ Deposit retained? 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: T ✓
1. Obtain a written permit from Rexburg City Hall, 35 1111 East, before attempting to takE(an ate!
2. Take water only from the one fire hydrant designated by the city water department. jy(i✓n nLk /,f/ -e
3. Check out 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 e of $40 ^tt addition
to the normal charge for the water tak 3ny(Zt'� n��/
L/
2A _ l _ d3 Signature of App Ica 2u I
REFUND TO:
METER OK:
Issued by:
YES OUT READ 10 it
NO IN READ 19
GAL. USED _�9 AM
READ DATE
METER RE -ISSUED? YES / NO
CHARGES:
METER MAINT 75.00
0- 1000 GAL _10.00
ADDITIONAL WATER
REPAIRS -PAR
TOTA
Received by:
Business name
Picked up by
Address:
4�
Deposit amt: (Receipt
$1,800- 2" Water Met
$ 800 - 1" Water Met,
CONDITIONS OF PERMIT`
In order to prevent pl
desiring to obtain water f
1 Obtain a written 1
2. Take water only fi
3. Check out the bac
agreed upon by th
4. As indicated above
will be paid for by
deposit win be reft
5• The fee for any wa
Fee: 1 - 1,
i . A 550.00 maintena
maintenance on th
7. The meter needs tt
request if needed.
Any person or entity not
to the normal charge for I
REFUND TO:
METER OK; YES
NO
RI
iJ
MET
Issued
Issued by: (j(j,/_---- I j