Water Tap Application Form

ST, CHARLES MESA WATER DISTRICT 1397 Aspen Road Pueblo, Colorado 81006 719 542-4380 FAX 719 542-4862

Parcel No. (required)

Date of Application (required)

Plot Plan/Survey (required)

Time of Application (required)

Legal Description/Subdivision (required)

The undersigned hereby makes application for a service connection to the St. Charles Mesa Water District water system. The service connection is for a single family dwelling.

First Name (required)

Last Name (required)

Spouse

Home Phone (required)

Work Phone (required)

Service Address (required)

Commercial or Residential? (required)

Commercial

Residential

Mailing Address (If different).

TERMS AND CONDITIONS

The St. Charles Mesa Water District of Pueblo, Colorado, hereafter referred to as the "District" has established Rules and Regulations for the operation of the District. Every patron receiving water from the District water system is deemed to have consented to and agreed to abide by those Rules and Regulations, and to have acknowledged the right of the District to discontinue water service in the event of the failure of such customer to comply with those Rules and Regulations, including making timely payment of all charges.

Please initial to verify your understanding of the terms and conditions stated above. (required)

Please initial to verify your understanding of the information listed on the back of this application. (required)

Please initial to verify your understanding that any property that has been irrigated by the Bessemer Ditch since May 11, 2006 and must supply a share of Bessemer Irrigation Ditch Company Stock in order to receive water service as required by Article XI of the District’s Rules and Regulations. (required)

Please initial to verify that your property has never had Bessemer Irrigation Ditch Company Stock or has had the stock sold prior to the Adoption of Article XI, Section 19.01 May 11, 2006 and is requesting to purchase a share from the Water Bank. (required)

Applicant(s) agree(s) to grant such right-of-way for water pipeline, or other necessary appurtenant facility, as may be required or deemed necessary by the District, such right-of-way not to exceed twenty (20) feet in width and to be located as conveniently as possible without damage or injury to permanent improvements of the applicant.

All water meter assemblies shall be installed by the District in a location and manner approved by the District. Failure by the customer or the customer's agent to protect water meter assembly shall result in the District charging the customer the actual cost of repair of the damaged water meter assembly.

Applicant (required)

FOR OFFICE USE ONLY

Connection Charge

Bessemer Irrigation Share

Yes

Water Bank

Tap Location

East

West of the St. Charles River

Line Extension Charge

Subdivision Approved Prior to May 10, 2006

Yes

Approved by

DATE (mm/dd/yyyy)

Please Read Carefully:

1. Interconnection of properties is prohibited.

2. A shut off valve going into residence and/or business is required by District.

3. All internal and external plumbing shall comply with Pueblo Regional Building and Colorado Department of Health & Environment Primary Drinking Water Regulations

4. Service line between the meter and the house shall not be smaller than one (1) inch in diameter.

5. The minimal monthly service charge for each tap shall commence thirty (30) days after payment of the tap fee.

TITLE IV

Building Regulations Chapter 4 Plumbing

(2) All new orreplaced water service piping fewer than two (2) inches (51mm) from the main to the meter shall be no lighter than Type L Copper or PEX, PE-AL-PE, and PEX-AL-PEX pipe. A blue 14-gauge tracer wire shall be installed with all nonmetallic water services. All service piping two (2) inches (51 mm) or larger shall be Type K Copper, Class 50 or Ductile ron, or PVC American Water Works Association approved pressure pipe or other approved material. Water service piping shall be installed to a minimum of forty-eight (48) inches (1,219.2 mm) depth from the top of the pipe.

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