BAY COUNTY DEPARTMENT OF WATER AND SEWER
3933 PATTERSON ROAD, BAY CITY, MI 48706-1993
(989) 684-5510
SERVICE CONNECTION APPLICATION

TOWNSHIP/DISTRICT: Residential
Date:     Received By: ___________________ Commercial
Name:      Telephone # (H)      (W)
Service Address:      Lot #
Mailing Address:      City:      ZIP:
Between Road and Road on Side
Property Code Number      Sec #      Route #      Read Sequence #
Connection Size      Domestic Meter Size      2nd Meter Size

WATER

Township applica. Fee payable @ DWS. . . . . . $_______
Connection Fee. . . . . . . . . . . . . . . . . . . . . . . . . . . $_______
Meter Fee(s). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $_______
Inspection Fee. . . . . . . . . . . . . . . . . . . . . . . . . . . . $_______
Capital Improvements. . . . . . . . . . . . . . . . . . . . . $_______
Additional Construction Costs. . . . . . . . . . . . . . $_______
TOTAL DWS COST. . . . . . . . . . . . . . . . . . . . . . . . $_______
Township Debt Fee. . . . . . . . . . . . . . . . . . . . . . . . $_______
To be paid at Twp. And proof to DWS Personnel before scheduling inspection.
Sht#_____ Long _____ Short _____
Water Main Size/Type ___________

SEWER

Township applica. Fee payable @ DWS. . . . . . $_______
Inspection Fee. . . . . . . . . . . . . . . . . . . . . . . . . . . $_______
Additional Construction Costs. . . . . . . . . . . . . . $_______
TOTAL DWS COST. . . . . . . . . . . . . . . . . . . . . . . . $_______
Township Debt Fee. . . . . . . . . . . . . . . . . . . . . . . . $_______
To be paid at Twp. And proof to DWS Personnel before scheduling inspection.
Sht#_____ Tap @ PL_____ REU Factor_____
Flag Person Required: Yes___ No___
Close Road: Yes___  No___
Notify:_________________________
Grease Trap Required: Yes___ No___
Backflow Preventor Required: Yes___ No___
Frost-Breaking Charges of $36.00/hr. may be in effect from November 15th to March 31st.
Special District Billing Code?     KF water "K" P1 sewer "P"

Additional Comments:____________________________________________________________


Approved:   Person Notified:___________________________

Date:___________________ Time: ___________

Quote/Cost Valid through (30 days) ____________

Notified of Frost-Breaking Charges: Yes___  No___

Notified debt fee receipt is required before inspection will be scheduled: Yes___  No___  Not applicable___

________________
Initials

________________
Date