Village/Town of Somers Hydrant Use Permit

Village/Town of Somers Hydrant Use Permit
Permit Number:*
Issue Date:*

MonthDayYear
Renewal?*

YesNo
TO BE VALID THIS PERMIT MUST BE KEPT IN THE VEHICLE. VOID AFTER EXPIRATION DATE. Failure to return a hydrant meter or wrench in good condition will result in the current charge for replacement of items loss or damage.
SEND WATER BILL TO: Name*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*

Area CodePhone Number
Email:*
example@example.com
Purpose: (Check as Needed)*

flushing water/sewer maingeneral constructionSomers Water Utility contracttank fillingVillage/Town of Somers contractwater sodOther
Location used at:*
HYDRANDT CHARGES - NOTE: All hydrants used shall be metered unless exempted by a Somers Water Utility Supervisor. Wrench may be issued with Hydrant Use Permit. All hydrants shall be metered. Meters will be placed at designated location by Somers Water Utility Employee. Meter will be left at this location. Please notify Somers Water Utility when hydrant meter is done being used (262) 859-2822.
Meter Needed:*

YesNo: Exemption Approved By: (SWU Supervisor)
Service Charge (quarterly or less than 90 days) (07-4740) @ $55.00*

YesNo
Unmetered Water Charge: (Residential & Small Commercial $100.30 quarterly (1" or smaller) (07-4600) @ $100.30*

YesNo
Install Temporary Meter (Large Commercial, Industrial or Apartment Buildings (above 1" or larger) (07-4600) ( charge per size of meter) @ $_____*
Hydrant Meter Service Charge: (5/8" or 3/4" meter) (07-2320) @ $31.27*

YesNo
Hydrant Meter Service Charge: (3" meter) (07-2320) @ $168.83*

YesNo
Swimming Pool Service Charge - Business hours (07-4740) $160.00*

YesNo
Water Usage billed per current Rate Structure Sheet (per 100 cubic ft.)*
TOTAL DUE:*
FOR OFFICE USE: METER INFORMATION
Size
Meter Mfg.
Serial No.
Reading
Date Returned

MonthDayYear
Date
Ending Reading
Date Wrench Returned

MonthDayYear
Date
To Whom
Meter in Operating Condition?

YesNo
All Parts Returned?

YesNo
Signature Meter Supervisor

Clear
Date

MonthDayYear
Date
Okay to Close Our Permit?

YesNo
Original: Billing Office

Copies: Public Works/Water Dept. Applicant
Should be Empty: