Application Form For Non-Residential Water And Sewer Customer Service printable pdf download

City of Adrian

Utilities Department

135 E. Maumee Street

Adrian, Michigan 49221

Phone

(517) 264-4821 Fax

(517) 266-4693

Non-Residential Water and Sewer Customer Application for Service

The purpose of this document is to screen applicants for water and sewer service for the following: assurance size of service is

adequate; determine impact fees and tap fees; determination if a water backflow device is needed; determination if an Industrial

Pretreatment Permit is needed; determination of applicable Non-Residential Charge; determination if a pre-treatment device is needed.

1. Facility Name

Account Number

2. Property Address

3. Mailing Address (if different from above)

4. Name/Title of Authorized Representative of Facility

Phone

5. Contact Person (if different from above)

Phone

6. Brief Description of Operation

7. Will there be an irrigation system?

Yes No

8. Will the facility use a grease trap?

(restaurants only)

Yes No

9. Will there be any discharges into the sanitary sewers other than from a restroom facility at this location?

Yes No

10. If “yes”, briefly describe the process(es) at this facility that has a discharge.

11. Are there any uses of water other than typical residential use?

Yes No

12. If “yes”, briefly describe water process(es).

13. Size of Service Requested:

Water

5/8”

¾”

1”

1 ½”

2”

4”

6”

8”

(Please circle)

Sewer

4”

6”

8”

14. Will there be fire suppression equipment?

Yes No If “Yes”, how many connections?

15. Will there be any fire hydrants?

Yes No If “Yes” how many?

16. If you answered “no” to questions 8 and 9, you may sign and date this form and return it to the Utilities Department.

17. If applicable, list Standard Industrial Classification(s) (SIC) at this facility.

18. Source of supply water to facility:

City of Adrian

Well

19. Are roof drains connected to the Storm Sewer Sanitary Sewer Do Not Know

20. Are floor drains connected to the Storm Sewer Sanitary Sewer Do Not Know

21. Disposal Practices A) How are spent (used) chemicals disposed of at this facility?

B) How do you dispose of spoilage?

Certification Statement “I certify under penalty of law that this document and all attachments were prepared under my direction or

supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information

submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering

the information, the information submitted is, to the best of my knowledge and belief, true, accurate and complete. I am aware that

there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing

violations.”

Signature____________________________________Title________________________________________ Date_________________

Note: Payment of impact fee and tap fee is required prior to building permit issuance. Applicants requiring Industrial Pre-Treatment

Applications will not be approved until after submittal and review of application.

For Office Use Only

Water Service Size_____ Water Impact Fee________ Water Tap Fee_________ Sewer Service Size ____Sewer Impact Fee_________

Fire Service Connection Fee__________Total Fees____________Backflow Device Required

Pretreatment Device Required

The City of Adrian reserves the right to determine type and location of required Backflow devices or pretreatment devices.

Approved by: Chief Chemist__________ Office Mgr__________ Distribution/Collection__________ Utilities Director___________

Application Form For Non-Residential Water And Sewer Customer Service

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