Village of Kingsley
207 S. Brownson
Kingsley, Michigan 49649
Phone: (231) 263-7575

Date:


Name of Applicant:


Phone Number:


Email Address: (required)


Address of Requested Service:


Name of Contractor:


Phone Number of Contractor:


Address of Contractor:


Contractor's Proof of Insurance:


Property Zoning:
Residential Commercial Industrial

---

Water

Size of Service:
1 inch 1½ inch 2 inch 4 inch Other

Size of Meter:
5/8 inch 3/4 inch 1½ inch 2 inch 3 inch
Other

Type of Service:
Replacement New Service
(All service connection pipes must be type K unless otherwise specified by Village)

Will Property have a
steam or hot water boiler sprinkler system
* If you have answered yes to one of the above, a Backflow Preventor is required.

---

Sewer

Name and address of contractor if different:


Contractor insurance information:


Type of Service:
Replacement New Service

Size of Service:
4 inch 6 inch 8 inch Other

Type of Pipe Used:

Schedule 35 or 40 PVC pipe is usually used)
Note: Property owner is responsible for ALL cost of service

---

Signature: