Fillable Eng-sewer-form-nonresidential-fillable TOWN OF HUDSON, NEW HAMPSHIRE

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Eng-sewer-form-nonresidential-fillable TOWN OF HUDSON, NEW HAMPSHIRE

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  • 3 check-boxes
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Country of origin: US
File type: PDF

U.S.A. forms for Town of Hudson

BROWSE TOWN OF HUDSON (NH) FORMS

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C:\Users\elvis\Desktop\SEWER FORM NON-RESID.docx Revised 2/26/14
TOWN OF HUDSON, NEW HAMPSHIRE
SEWER CONNECTION APPLICATION FOR
INDUSTRIAL, COMMERCIAL AND BUSINESS FACILITIES
NOTE: THIS FORM WILL NOT BE ACCEPTED UNTIL SECTION 1 HAS BEEN
COMPLETED AND APPLICATION FEES HAVE BEEN SUBMITTED.
1. OWNER INFORMATION
NAME: ___________________________________________________________
ADDRESS: ___________________________________________________________
TELEPHONE: _______________________________ EXT: ______________________
BUILDING
LOCATION: ___________________________________________________________
TAX MAP: _________ ___ LOT: ______________________
FUNCTION OF BUILDING:
(i.e. Retail, Manufacturing, Offices, etc.)_______________________________________
STATUS OF SEWER CONNECTION:
NEW CONNECTION REPAIR OR REPLACEMENT
NO NEW CONNECTION – CHANGE OF USE OR BUSINESS / MODIFICATION
NUMBER OF EMPLOYEES
(Indicate shifts, if applicable):_ ______________________________________________
SEWERAGE FLOW: ________________________/GPD
BY APPLYING FOR THIS CONNECTION, I AGREE TO ABIDE BY ALL APPLICABLE
TOWN, STATE AND FEDERAL REQUIREMENTS.
SIGNATURE: __________________________________________________________
OWNER OR AGENT FOR OWNER:
IF DIFFERENT FROM ABOVE, INCLUDE ADDRESS AND TELEPHONE NUMBER:
________________________________ ___
Name: Address: Phone #:
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C:\Users\elvis\Desktop\SEWER FORM NON-RESID.docx Revised 2/26/14
2. FEE PAYMENT
$25.00 PROCESSING FEE PAID:
DATE: __________ RECEIPT NO. ___________ __RECEIVED BY: _____________
$1,000.00 IDP REVIEW/INSPECTION FEE PAID:
DATE: ______________ RECEIPT NO. ___________ __RECEIVED BY: _______ ___
ACCOUNT #: ______________ NAME OF ACCOUNT: ____ _______________
3. SEWER FOREMAN REVIEW (if applicable):
________ STREET OPENING PERMIT REQUIRED (check if applicable)
SPECIAL CONDITIONS CLEAN OUT AT PROPERTY LINE, 24 HOUR
NOTICE PRIOR TO EXCAVATION - 886-6008
________________________________________________________________
________________________________________________________________
Sewer Foreman Date
4. TOWN ENGINEER REVIEW (check required and/or completed or
indicate not applicable)
_____ PLANS & SPECIFICATIONS REVIEW COMPLETE (if applicable)
_____ STATE REVIEW FEE: Flow ( ) GPD / 300 GPD X $30.00
FEE: $____________; DATE SUBMITTED TO STATE: ___________
_____ STATE APPROVAL GRANTED
_____ INSPECTION FEE REQUIRED: $_______________________
_____ SEWER CAPITAL ASSESSMENT FEE CALCULATION (refer to
Town of Hudson resolution 87-33A.)
a) AVERAGE DAILY FLOW IN GPD ________
b) AVERAGE DAILY FLOW EXISTING (if any) - ________
___ _____
= net flow X $3.53 ASSESSMENT FEE: $___ _____
APPROVED ___________ DISAPPROVED ____________
C:\Users\elvis\Desktop\SEWER FORM NON-RESID.docx Revised 2/26/14
SPECIAL CONDITIONS _________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
TOWN ENGINEER DATE
5. DATE SEWER CAPITAL ASSESSMENT PAID: ____________________________
RECEIPT NO. __________________RECEIVED BY:_________________________
6. PAYMENT AGREEMENT: _____________ YES __________ NO
APPROVED __________ DISAPPROVED __________
______________________________________ _____________________
FINANCE DIRECTOR (approval of agreement) DATE
7. SEWER CONNECTION CERTIFICATION
DATE OF CONNECTION: ____________________________________________
INSPECTED BY: ____________________________________________
SIGNATURE: ____________________________________________
DATE: ____________________________________________
BUILDING LOCATION: ____________________________________________
TAX MAP: ____________________ LOT: ____________________
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Eng-sewer-form-nonresidential-fillable TOWN OF HUDSON, NEW HAMPSHIRE

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Completed 13 July 2020

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