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Apply for Water Service Connection

2. Instructions
   - The Member Municipality is to submit this application.<br> - Complete 1 through sixteen 16.<br> - Submit the form.

   - 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.<br> - Tapping materials and procedure must comply with Champlain Water District, Wholesale Department specifications.

    - 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:

    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