Town of Milton, Vermont, 05468 ● Water and Wastewater Department
Application for Water Disconnection/Reconnection
Phone ● (802)893-6030 Fax ● (802)893-1005 Email ● telwood@miltonvt.gov
THIS APPLICATION MUST BE SUBMITTED NO LATER THAN 2 CALENDER DAYS PRIOR TO REQUESTED
SERVICE DATE. PAYMENT IS EXPECTED IN FULL PRIOR TO SERVICE UNLESS AN EMERGENCY.
Owner(s): Applicant(s): __________________________
Address: Address:______________________________
Phone Day: ________________ Phone Night:________________ Fax #: ________________
Location of Work (address, lot or parcel number):____________________________________
Reason for Request: __________________________________________________________
Date/Time Disconnect Requested: __________/ 20____. ____:____ am/pm
Date/Time Reconnect Requested: __________/ 20____. ____:____ am/pm
Work to be performed by: Phone: ________________
The undersigned in consideration of the approval of this permit, having fully read all of the contents herein and attached,
expressly agree to the directions, restrictions and conditions on or attached to this request for service.
Signature: __________________________________________________ Date: _____________
Owner/Applicant
Print: _______________________________________________________
Owner/Applicant
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Conditions of Approval:____________________________________________________________
Signed: Title: Superintendent Date:___________ 20____
Dept. Use Only
On/Off Fee: $25 per visit Total Due: $___________ Date paid: ___________/ 20______ Rec’d by int: _________
