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 2^nd 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 15^th to March 31^st.

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