JERICHO-UNDERHILL WATER DISTRICT

P.O. Box 174, Underhill, Vermont 05489

(802) 899-3810

APPLICATION FOR WATER ALLOCATION

Date: _______________________

Customer Name: ________________________

Customer Address: ________________________

________________________

________________________

Tax Property Code ________________________

Property Address (if different):_______________________

________________________

________________________________ hereby requests allocation of drinking water.

(Customer)

The requested allocation is ________________________________gallons per day.

The use or purpose of this allocation is __________________________________.

This allocation request is based on the following considerations and calculations:

____________________________________________________________________________________________________________________________________________________________

This allocation is in conformance with the design flow specified in the currently effective version of the State of Vermont, Environmental Protection Rules, Chapter 1 Wastewater System and Potable Water Supply Rules, Subchapter 1-504.

_____________________________________

(Signature of customer)

Reviewed by the District Board on ___________________________

(Date)

Accepted _____________;

Rejected _______________. Reason (if rejected) _____________________________________

_______________________________________

(Signature of Clerk)

Content updated on: "2/8/2006"