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2. Instructions
   - The Member Municipality is to submit this application.
   - Complete 1 through sixteen 16.
   - Submit the form.
4. 1. Member Municipality Applying
6. 2. Member Municipality Contact Person
   Please enter the name and phone number of the contact person.
8. 3. Member Municipality Mailing Address
10. 4. Location of Proposed Connection
12. 5. Name of Property Owner
14. 6. Mailing Address of Property Owner
16. 7. Number of Sprinkler Systems or Hydrants
18. 8. Water Demand (Gallons per Day)
20. 9. Size and Type of Connection
22. 10. Expected Use Type

    1. Municipal
    2. Hydrant
    3. Residential

    1. Commercial
    2. Industrial
    3. Other
24. 11. Acreage Served by Tap
26. 12. Frontage Along Water District Pipeline
28. 13. Number of Users on Tap
30. 14. Backflow Device to be Used
32. 15. Instructions
    - Champlain Water District must be notified at least 3 working days prior to the tap.
    - Tapping materials and procedure must comply with Champlain Water District, Wholesale Department specifications.
34. 16. Certifications
    I hereby certify that this information is correct to the best of my knowledge and that the connection will be made according to specifications of the Champlain Water District and will be supervised by the Town of:
36. Town
37. Name
38. Date
    Date
42. 17. Application Received by
43. Application Received on
45. 18. Application Approval

    1. Approved
    2. Rejected
47. 19. Comments
49. 20. Name
50. Title
51. Date
    Date
Leave This Blank:


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit

* indicates a required field