HomeMy WebLinkAboutMid-Valley MetroNumber of Prepaid EQRs to be applied to this tap:
Owner of Prepaid EQRs:
rVA-
Mid Valley Metropolitan District
0031 Duroux Lane, Suite A - Basalt, CO 81621
Tel: (970) 927-4077 • Fax: (970) 927-1017 mvmd@sopris.net
Business Hours: Monday - Friday, 9:00 a.m. - 3:00 p.m.
APPLICATION FOR WATER AND SEWER SERVICE AND TAP PERMIT --
SINGLE-FAMILY, RESIDENTIAL, SECONDARY
RESIDENTIAL, DUPLEX AND SPECIAL CLASSIFICATIONS
*Please complete and return to Mid Valley Metropolitan District*
Name of Applicant: % E:I i Ff,6,,P.co.AZ
Address: VJ. Q L . 2c , a . 5 / - 2-.77
Phone: (H) 97 % 7 i Z5.3. (W) 9 7z7 379 940 (Fax)
(Ce1D —379 SG� /
Service desired: Water / Sewer ✓
{Email) ! & /27 i {fcMFi 'F rriC,�� e_&r'f
Owner of Property to be Served: /4,4, vC
Address: %/sic- Q Phone: r//�� £
Street Address of Property to be Served: !�G �� , r.,g gAce4c,f.4r --
Subdivision or Development: ��eS6- 2 ¢:&-Vf- Block/Lot: 2-
Structures on Property (if there is more than one structure of the same type, give separate information
for each):
SFD & Duplexes ADU
Bedrooms:
Kitchens:
Bathrooms
Square feet of Irrigated Green Space:
Other water uses or structures (e.g.hot tubs,
swimming pools, fountains)
Number of EQRs Required, per District EQR Schedule: i
l4-
4-
7.
x
Address: Phone:
NOTE: Attach a copy of the document which assigns the prepaid tap to you. Unless attached,
no credit for the prepaid tap will be granted.
Number of free EQRs to be applied to this tap: Ni ( 4
Owner of free EQRs:
I, the applicant named above, as lawful owner of the property described above or on behalf of
the lawful owner, hereby apply to Mid Valley Metropolitan District for the privilege of water and/or
sewer service pursuant to §6.03 of the District's Rules and Regulations. I certify that the above
description of the property to be served, and the structures thereon, is accurate. I understand that I
must have the new tap inspected by District representatives and hereby consent to an inspection of
the premises at a reasonable time and in a reasonable manner for the purposes of approving the tap
and verifying the tap fee to be charged. I agree to give the District 24 hours notice before such an
inspection is needed. I understand that service charges begin to accrue from the date of physical
connection. I agree to abide by the Rules and Regulations of the District as set by the Board of
Directors and amended from time to time, and to notify the District of any changes in the structures
or water uses described in this application.
Applicant
Date r //7/�
OFFICE USE ONLY
Copy of water and sewer policy given? Rules & Regulations offered? EQRs 1
Tap fee paid: Water $ 14q.. DV Date 1 ! -7 72024 Received by (, [.
Sewer $ nOq6,• Q6 Date 1 '1' Received by (Lid(
Inspection Deposit $ 2 () Date l// / 2 02-1 Received by 4 A
Water rights dedicated?
NJ/A
Surcharge paid $ 1 I (ZO ,
Application approved (becomes a tap permit): Date 7 CJ 1 By
Account number assigned 7370.06.0I Inspection scheduled for
Comments
4
CRB 118-2
1 MID VALLEY METRO DISTRICT
0031 Duroux Lane, Suite A
Basalt, CO 81621
T: (970) 927-4077, F: (970) 927-1017 1