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APPLICATION FOR NEW WATER AND/OR SEWER SERVICE

TOWN OF

PETERBOROUGH

PUBLIC WORKS – UTILITIES DIVISION

Peterborough, NH 03458

Date: _________________

I___________________________________of_____________________________________________________________

For the property located at ______________________________apply for a water and/or sewer service connection from the

Town water/sewer main to the property described herein. This application is made in compliance with the rules and regulations

of the Town of Peterborough. A sketch of the proposed services will be submitted with this application.

THE CONNECTION FEES (Submitted with this application.) Water $_______________Sewer $_______________

THE INSPECTION FEES

Water$ _______________Sewer $_______________

THE WATER METER INSTALLATION FEE of $________ (Submitted with this application.)

Contractor shall coordinate construction and inspection with the Department of Public Works at 603-924-8000 x100.

The owner shall be responsible for maintaining the service lines on his/her property, upon completion of the service lines

installation.

_________________________________

___________________________________

Public Works Director/Utility Superintendent

Property Owner Signature

The Town of Peterborough’s Water & Sewer projects are feasible due to funding by federal grants and loans. One of the

requirements for this funding is to obtain, from our customers on a voluntary basis, the answers to the following questions.

Failure to participate will not affect your level of service.

Race and Ethnicity: (Note: both Part A and B of the question must be answered

Part A:

Is the owner Hispanic/Latino? (Choose only one)

No, not Hispanic/Latino

Yes, Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican,

South or Central American, or other Spanish culture or origin, regardless of race.)

The above part of the question is about ethnicity, not race. No matter what you selected above, please continue to answer the following by

marking one or more boxes to indicate what you consider your race to be.

What is the owner’s race? (choose one or more)

Part B:

American Indian or Alaska Native (a person having origins in any of the original peoples of

North and South America (including Central America), and who maintain tribal affiliation or

community attachment.)

Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or

the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia,

Pakistan, the Philippine Islands, Thailand, and Vietnam.)

Black or African American (A person having origins in any of the black racial groups of Africa.)

Native Hawaiian or other Pacific Islander (A person having origins in any of the original peoples

of Hawaii, Guan, Samoa, or other Pacific islands.)

White (A person having origins in any of the original peoples of Europe, the Middle East, or North

America.)

I attest that the information contained herein is correct to the best of my knowledge.

(Owners’ Signature)

(Date)

Application For New Water And/or Sewer Service Form - Town Of Peterborough Public Works - Utilities Division

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