APPLICATION

WATER AND/OR SEWER SERVICE AVAILABILITY

THIS FORM IS TO BE FILED WITH GREENSVILLE COUNTY WATER & SEWER AUTHORITY PRIOR TO SUBMITTING BUILDING PERMIT APPLICATION TO BUILDING OFFICIAL.

Applicant:              NAME:_______________________________________________________________________

MAILING ADDRESS: __________________________________________________________

PHONE NUMBER:_____________________________________________________________

 LOCATION OF PROPERTY:__________________________________________________

(complete description including location of structure, location of two closest adjacent structures, road name, and plat of the property, if available)

SERVICE NEEDED: WATER:_____ SEWER:______ GREENSVILLE:________ JARRATT:______

                                     SUSSEX:________ OWNER OCCUPIED______ __ TENANT OCCUPIED:_____

_____________________________________________                __________________________________________

           SIGNATURE OF APPLICANT                                                        DATE OF REQUEST

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THIS SECTION TO BE COMPLETED BY THE ENGINEERING DEPARTMENT

SERVICE AVAILABILITY

    WATER                                                                                      SEWER

____Tap Currently in Place                                      ____Tap Currently in Place

____Tap Must be Constructed                                          ____Tap Must Be Constructed

         (1 to 3 weeks required)                                                        (1 to 3 weeks required)

____Tap Must be Constructed                                          ____ Tap Must Be Constructed

        Across Right-of-Way Greater                           Across Right-of-Way Greater

        Than 50 feet, Approximate                                                  Than 50 feet, Approximate

        Construction Cost $_______                                             Construction Cost $_______

____ Service Available with Minor Line                           ____Service Available with Minor Line

         Extension, Approximate Cost $______                     Extension, Approximate Cost$_____

____ Service Not Available Without                                      ____ Service Not Available Without

         Major Line Extensions                                                      Major Line Extensions

 NOTES_____________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

Authority Staff                                                                    Title                                                                    Date

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THIS SECTION TO BE COMPLETED BY THE CASHIERS OFFICE

(FEES NOT GUARANTEED BEYOND 60 DAYS)

Water Tap$_______ Sewer Tap$______ Deposit$________ Account Charge$________ Disconnect Fee$________

 Total Amount Due$_________   FEES ALREADY PAID YES OR NO

 COMMENTS:________________________________________________________________________________

_____________________________                ___________________________               ______________

             OFFICE STAFF                                                             TITLE                                                            DATE

ONE COPY TO CUSTOMER, ONE COPY FORWARD TO BUILDING DEPARTMENT, AND COPY TO FILE.

GCWSA

REVISED 10/98 ljp