Village/Town of Somers Hydrant Use Permit

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

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Renewal?
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)

Other
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:
Service Charge (quarterly or less than 90 days) (07-4740) @ $55.00
Unmetered Water Charge: (Residential & Small Commercial $100.30 quarterly (1" or smaller) (07-4600) @ $100.30
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
Hydrant Meter Service Charge: (3" meter) (07-2320) @ $168.83
Swimming Pool Service Charge - Business hours (07-4740) $160.00
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
2 digit month, 2 digit day, 4 digit yearDate
Ending Reading
Date Wrench Returned

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
To Whom
Meter in Operating Condition?
All Parts Returned?
Signature Meter Supervisor
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Okay to Close Our Permit?
Original: Billing Office

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