E-Mail Address *
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Date
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Name of Applicant
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Phone #
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Address of Requested Service
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Name of Contractor
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Phone # of Contractor
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Address of Contractor
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Contractor's Proof of Insurance
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Property Zoning (Residential, Commercial, Industrial)
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Water
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Size of Service
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Size of Meter
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Type of Service (All service connection pipes must be type K unless otherwise specified by Village)
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Will property have a: (if you select one of these, a Backflow Preventer is required)
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Sewer
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Name of Contractor, if different
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Address of Contractor, if different
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Contractor's Proof of Insurance
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Type of Service
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Size of Service
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Type of Pipe Used: (Schedule 35 or 40 PVC pipe is usually used)
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NOTE: Property owner is responsible for ALL costs of service.
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Signature *
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