DATE RECEIVED:
RECEIVED BY:
CITY OF LA GRANDE
UTILITY REQUEST FORM
ALL DATA IS TO BE COMPLETED BY APPLICANT
PLEASE RETURN THE COMPLETED FORM TO THE
PUBLIC WORKS DEPARTMENT
800 ‘X’ AVENUE, LA GRANDE, OR 97850
OR FAX TO: (541) 963-3608
RESPONSE TIME IS 10 BUSINESS DAYS
APPLICANTS NAME:
MAILING ADDRESS OR FAX NO:
PHONE NUMBERS: HOME: BUSINESS: CELL PHONE:
PLEASE ATTACH A COPY OF THE ASSESSORS MAP WITH THE PROPERTY HIGHLIGHTED
PLEASE PROVIDE A LEGAL DESCRIPTION OF THE PROPERTY FOR WHICH SERVICE IS BEING REQUESTED
T S R 38 E SECTION TAX LOT
SUBDIVISION: BLOCK LOT(S)
STREET ADDRESS OF THE PROPERTY:
PROPOSED PROPERTY USE
PLEASE SELECT ONE OF THE FOLLOWING (TO BE COMPLETED BY APPLICANT)
RESIDENTIAL
NEW BUILDING SINGLE FAMILY MANUFACTURED HOME
MULTIPLE FAMILY (DUPLEX - 2 UNITS)
(LOCATION OTHER THAN EXISTING SUB-DIVISION)
EXISTING BUILDING MULTIPLE FAMILY (3 OR MORE UNITS) PARK
TEMPORARY USE
COMMERCIAL
INDUSTRIAL
NEW BUILDING NEW BUILDING
EXISTING BUILDING EXISTING BUILDING
TYPE OF BUSINESS:
APPROXIMATE FLOOR AREA: NUMBER OF PEOPLE TO BE SERVED:
NOTE: COMMERCIAL AND INDUSTRIAL USER MUST COMPLETE A DATA DISCLOSURE FORM. RESTAURANTS MUST COMPLETE AN
EASTING ESTABLISHMENT FORM. THESE FORMS MAY BE OBTAINED AT THE PUBLIC WORKS DEPARTMENT (541) 962-1325.
EXISTING UTILITIES ON THE PROPERTY
WATER
NONE
WELL
CITY
SANITARY SEWER
NONE
SEPTIC TANK
CITY
STORM SEWER
NONE
DRY WELL
CITY
SERVICES REQUESTED
(PLEASE STATE THE SIZE OF THE SERVICE REQUESTED, INCHES IN DIAMETER.
IT IS THE RESPONSIBILITY OF THE APPLICANT TO DETERMINE THE REQUIRED SIZE)
WATER “ DOMESTIC “
IRRIGATION “
FIRE
SEWER “ SANITARY SERVICE “
STORM SEWER SERVICE
APPLICANTS SIGNATURE: DATE:
ANY INFORMATION MISSING MAY DELAY THE RESPONSE OF YOUR REQUEST. RESPONSE TIME IS 10 BUSINESS DAYS.
PUBLIC WORKS STAFF USE ONLY
NEW SERVICE
REPLACEMENT SERVICE
IS CUSTOMER OUT OF SERVICE YES NO
IF YES, IS THIS AN EMERGENCY YES NO
POSSIBLE PLANNING DEPARTMENT ISSUES: YES NO
FINANCE STAFF USE ONLY
PAYMENT/LID INFORMATION:
DOES THE PROPERTY HAVE ANY CURRENT LID LIENS? YES NO IF YES TOTAL AMOUNT DUE $
ARE THE LID PAYMENTS CURRENT? YES NO IF NO AMOUNT PAST DUE $
PLEASE CHECK IF APPLICANT HAS A BILLING ACCOUNT? YES NO IS IT PAST DUE, HOW MUCH? $
PLEASE CHECK IF ADDRESS HAS A BILLING ACCOUNT? YES NO IS IT PAST DUE, HOW MUCH? $
Finance Staff Who Researched the Information: DATE:
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