Water and Sewer Fee Determination - Customer Application Form

Applicant Name (entity requesting service):*

Phone No.:*

Email*

Address of Applicant:*

Street Address Address Line 2 City State ZIP Code

Address of Property to be served:*

Street Address Address Line 2 City State ZIP Code

Zoning Application:*

Inside Martinsville City Limits (circle):*

YES

If zoning and city limits information is unknown the Engineer will make the determination. Your application for service can be denied if the property is not properly zoned for the intended use.

Describe Use, including but not limited to: retail sales; general office; restaurant; including fast or carry out foods; grocery; convenient store; gasoline station; professional office, doctor, dentist, clinic, hospital or nursing home; barber or beauty shop; service club, church, civic or fraternal organization; school, college, daycare or library; stage or movie theater; hotel. motel, apartments (more than four units); assisted living or retirement center; car wash; self service laundry; correctional facility; jail or prison; industrial, manufacturing, warehousing, service or repair, dry cleaners, body shop, engine repair, brake/muffler, computer, electronics, contractors, or appliances; recreational facility, picnic areas, campground, racetrack, sport park, open-air stage. IF MULTIPLE USE DESCRIBE ALL USES!

Size of Water Meter requested:

Number of restrooms:

Number of fire hydrants on private property:

If fire service connection required circle size:

Automatic Fire Sprinkles (circle):

YES

Kitchen facilities:

YES

A bar or bar area:

YES

Shower or shower facilities:

YES

Seating capacity for restaurant, theater, church, service club:

Number of chairs, beds, exam tables (barber, beauty, doctor, dentist, clinic, hospital):

Total Number of employees, students, children, teachers, residents, avg, attendance (race track, sport park, open-air stage) in 24-hr period:

Number of: rooms (hotel/motel), bays (car wash), machines (laundry), car spaces (drive-in restaurant), inmates (jail or prison, visitors (picnic area, fairgrounds), campsites (campground):

Number of parking spaces:

Hours of operation:

Number of shifts:

Building are (square feet) for (retail sales, occupied space (excluding storage):

Restaurant area (square feet):

Other use area (list use under remarks):

Other Information