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Required fields are marked with asterisks (*)

Temporary Water Supply for Construction

Complete this form to apply for temporary water supply for construction.

Please review Conditions on temporary water supply for construction before completing this form.

Your personal information is being collected under the authority of section 25 of the Local Authority Freedom of Information and Protection of Privacy Act. This information will only be used to administer the program/activity it was collected for. If you have any questions about the collection please contact the Office of the City Clerk at 780-875-6184 or email cityclerk@lloydminster.ca

Applicant Company Name:

Date:

Applicant Name:

Company Billing Address:

Contact Person:

Phone Number:

Alternate Contact Person:

Alternate Contact Number:

Email:

Intended Use of Temporary Water Supply: (Please provide as much detail of water volumes to be used)

Start Date: (When the water will be required)

Estimated End Date: (When the water will be required)

Specific Hydrant Location or Hydrant #:

By submitting this application and by signing this form, I affirm that the information provided is correct and I understand and agree with the conditions.

Signature: (Sign using your mouse or finger)

Clear

The following question is for office use only and do not require your answer.

Please click "SUBMIT" button at the bottom of the page to submit.

Water Use Approved By:

Date Approved:

Work Order Number:

Account Number:

Meter Read Start:

Meter ID:

Meter Read End:

Meter Box Connection Size:

Total Amount Used:

Meter Returned in Acceptable Condition?

YES

Date Meter Installed:

Meter Installed By:

Date Meter Removed:

Disconnected By:

Deposit Paid:

Receipt #:

Date: