MERRIMACK VILLAGE DISTRICT
ENTRANCE APPLICATION - 5/8" OR OVER

Line Size: _______
Circle One:
        Domestic
        Mercantile
        Industrial

Application to MERRIMACK VILLAGE DISTRICT (MVD):

I/we hereby apply for installation of an ENTRANCE at the following location(s).

____________ _______________________ ________________________________________________
       (Number)          (Street)                                    (Development)

I/we agree to pay the required charges in advance for this installation.

I/we agree to pay all of the extra charges if roadway is damaged during the construction of this ENTRANCE.

I/we understand there will be an additional charge for frost, ledge, abnormal natural barriers, bridging of
water and the like.

I/we agree to be responsible for the installation of a PRESSURE REDUCING VALVE if the location being developed is within the HIGH SERVICE area of Merrimack.

All services shall be the kind, type and size of pipe used and must have the approval of the MVD.

I/we agree to comply with the By-Laws of the MVD and the Schedule of Rates as adopted and passed by the MVD Board of Commissioners.

In the event of default of payment, the applicant agrees to pay for all costs of collection, including reasonable attorney's fees.

If the service is not installed within six (6) months from the date of this application, the entrance fee will be refunded to the applicant.

________________________________
(Applicant's Signature)

________________________________
(Printed Name)

________________________________
(Address)

________________________________
(City, State, Zip Code)

________________________________
(Telephone/Cell Number(s))

______________________________
(Date)

Approved by: ______________________________
                    (Business Manager/Superintendent)

_____________________________
(Date)