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FIRE HYDRANT USE PERMIT
NONTRADITIONAL WATER CUSTOMERS ^ Je GrxCI MCkC
CITY OF
35 North 1st East � __- - "—'--
Noah. ° REXBURG 6
Rexburg, ID 83440 Pheihean®rexburg.or _ 1\.D�/lll7
www.rexburg.org
Phone: 208.372-1137 CW
Date Issued gOrg Fox; 877.397.39/7 M"�w+rvmilr Cammmpy
/ Meter #J
Business name: )654-,07Permit # Hose Number— ^G
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Phone # a2m S-- G —n
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Address: �?i3 Phone#
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Year Issued- �� 6� L r
Deposit amt: (Receipt Code= WD
$1,800 - 2" Water Meter) with credit cards charge an additional 3.5% (Receipt Code= MISCG) 3/3-s/zQ22
$ 800 - 1" Deposit retained?
Water Meter or refunded?
CONDITIONS OF PERMIT: (date)
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:
I. Obtain a written permit from Rexburg City Hall, 35 N 1" East, before attemptingto take any water.
2. Take water only from the one fire hydrant designated by the city water department,
agreed upon by the user and the city water deptment.
3. Check out the backflow and metering device from the city water dept. to be attached to the fire hydrant "k BV A Sts-B-20-oon
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4. As indicated above a deposit will be required on any metering device. Any damage to or loss at the device
will be paid for by the user. After any use, repair, or replacement charges are deducted ,the balance of the
ater Quality
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: jl
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 ear for QQ or adt
y
maintenance on the meter. mat)
7. The meter needs to be returned by 12/1 for testing calibrations. A meter can be reissued the same day per tr
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 taken.
Signature of Applicant
REFUND TO:
METER OK: YES OUT READ 3D dt • CHARGES:
NO IN READ METER MAINT 75.00
GAL. USED 0- 1000 GAL 10.00
READ DATE ADDITIONAL WATER
METER RE -ISSUED? YES / NO REPAIRS -PARTS
TOTAL
Issued by:a)61Received by: