HomeMy WebLinkAboutHYDRANT PERMIT 2 - 21-00324 - Parks Department FHM 28r
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FIRE HYDRANT USE PERMIT
NONTRADITIONAL WATER CUSTOMERS
?' NorihIstFOS t'
Noah. v„ o
R''`qburg,ID83440 Phrfhaunwrexbur „I
www,rexburg rn.l f'tione: 208,372-2136
Date Issued Rix:877.391.3917
/ 1
Meter #F � Z
Business name: _�_ i�w Permit # L/ ..�3_—_
b,
Picked up by Phone #
i:lry or
REX—BURG
17*40
Arnerirui rr,roily Canmua ly
Hose Number:
Address: Gf 2� Phone #
Deposit amt: (Receipt Code= WpEp year Issued:
$111800-2„ Water Meter
J with credit cards charge an additional 3.5% (Receipt Code= MISCG
S 111111 Ift,
800' 1” Water Meter _ Deposit retained? )
CONDfTIONS OF 'ER -+L_ or refunded?
In order to prevent Ml1. ( date)
desiring to obtain t Possible contamination from backflow
water from a city fire hydrant
of the Rexburg city water system, an
1. Obtain a written permit from Rexburg
must comply with the following -
Y Persons or entity
2• Take water only from the one fire hydrant
City Hall, 35 N 1'i East, before attempting to take any water.
3. Check out the backflow and metering device frlom the gnated ct
y the city water department.
r
agreed upon by the user and the city water deptment, y water dept. to be attached to the fire hydrant
4• As indicated above a de
Will be posit will be required on an
Paid for by the user. After an y metering device. Any damage to or loss of the device
a
deposit will be refunded to the er anyruse, repair, or replacement charges are deducted ,the balance of the
1 5 The fee for l buser(city water dept. will conduct a final inspection.)
y water obtained through the metering device is as follows:
Fee' 1 — 1,000 gallons 10.00
6. A 550.00 maintenance fee for 1" $75.00
andach 1,000 gallons thereafter: $5.00
maintenance on the meter. maintenance fee for 2" will be assessed each year for
7 The meter needs to be returned by 1211 for testing calibrations. A meter can be reissued the
request if needed,
same day per
Y person or entity not complying with this policy shall be assessed a penalty charge of $400 in
addition
the normal charge for the water taken.
Signature 6fAnnlicant
?EFUND TO:
AE
TER OK.' YES OUT READrg
NO—`���f' CHARGES:
..______ IN READ y�'Z
GAL. USED METER MAINT 75.00
READ DATE 0- 1000 GAL
----- ADDITIONAL WATER 10.00
METER REISSUED? YES / NO
REPAIRS -PART
issued by: �/r^, /2 TOTAL
Received by: