CITY OF ELLSWORTH WATER DEPARTMENT
1 City Hall Plaza ▪ Ellsworth, ME 04605-1942 Phone (207) 667-8632 ▪ Fax (207) 667-4908 www.ellsworthmaine.gov
THE OWNER/CUSTOMER FURTHER AGREES TO THE TERMS AND CONDITIONS AS FOLLOWS:
That the department by its representatives, shall have the right to enter the premises of the Applicant at a reasonable time for the purpose of making such inspections as it may deem necessary, and it shall have the right to
attach any testing device or use any means it may elect to ascertain the condition of the pipe and appurtenances and the uses made of same. That the extent of the rights of the applicant under this Application is receive, such supply of
water as shall then be available and no other or greater. That the Applicant agrees that the department shall not be considered in any manner an insurer of property or persons, or to have undertaken to extinguish fire or to protect any
persons or property against loss or damage by fire, or otherwise and that it shall be free and exempt from any and all claims for damages on account of any injury to property or persons by cause whatsoever. That the rights and obligations
of the applicant hereunder shall be further subject at all times to the rates, rules, and regulations of the Department on file with the Maine Public Utilities Commissions, that now exists or which may hereafter be adopted of file. It is also
understood the above work does not include the replacement of shrubs, walks or driveways, lawns or gardens, and that the Department will be held harmless from any and all damages to property and structures resulting from the
construction performed on any premises.
ELLSWORTH WATER DEPARTMENT NEW SERVICE INSTALLATION APPLICATION
PROPERTY OWNER NAME:____________________________________________________________________________________________
PROPERTY OWNER ADDRESS:__________________________________________________________________________________________
PROPERTY OWNER PHONE NUMBER/EMAIL:______________________________________________________________________________
APPLICANT NAME
(IF DIFFERENT FROM PROPERTY OWNER):_____________________________________________________________________________
APPLICANT ADDRESS:____________________________________________________________________________________________________________
APPLICANT PHONE NUMBER/EMAIL:__________________________________________________________________________________________________
CONTRACTOR:____________________________________________________________________________________________________________________
CONTRACTOR ADDRESS:____________________________________________________________________________________________________________
CONTRACTOR PHONE NUMBER/EMAIL:________________________________________________________________________________________________
2. PROJECT INFORMATION RESIDENTIAL
SINGLE FAMILY RESIDENCE MULTI-FAMILY RESIDENCE- NUMBER OF UNITS______
APARTMENT BUILDING-NUMBER OF UNITS____ OTHER (PLEASE DESCRIBE)____________
PEAK DOMESTIC DEMAND (GPD)__________ AVERAGE DAILY DEMAND (GPD)_________
3. PROJECT INFORMATION COMMERCIAL
BUSINESS NAME:_________________________________________________________________
BUSINESS TYPE:____________________________________ NUMBER OF BUILDINGS:_____
PEAK DOMESTIC DEMAND (GPD)__________ AVERAGE DAILY DEMAND (GPD)___________
4. METER & FIRE PROTECTION INFORMATION
METER SIZE:_________ QUANTITY:_________ SIZE OF SERVICE LINE:__________
SPRINKLER SYSTEM: YES NO FIRE HYDRANT: YES NO
SIZE OF SPRINKLER SERVICE LINE:______ QUANTITY OF HYDRANTS:______
