v. 2018.10.12
** Form is not valid without Authorized Signature and Property Owner or Agent’s Signature **
City of South Bend
Department of Public Works
Utility Verification Form
Pursuant to the City of South Bend Municipal Code § 6-4.1 and 17-79 through 17-87, the Permit Manager's
Office has verified available utilities and connection requirements. This form is for the express purposes of
notifying an applicant of whether City utilities are available in a particular location and what requirements are
necessary for connection.
IT DOES NOT GUARANTEE CONNECTION TO CITY UTILITIES or CONSTITUTE A TAP PERMIT. The applicant must
meet the requirements below prior to receiving tap permits to connect to City utilities:
Property Information (To Be Completed By Applicant):
Property Owner’s Name: ___________________________________________________
Address/Lot #/Subdivision: ___________________________________________________
City, State, ZIP: ___________________________________________________
Single-Family Residential
Other
Inside City
Outside City & 1/8 Contiguous
Outside City & Not 1/8 Contiguous
The applicant is requesting the following connections:
Water
Sanitary Sewer
No. of ERUs*: ______ Peak Factor: ______
*
Equivalent Residential Unit (ERU) = 310 GPD
Residential Peak Factor = 4
City Requirements (To Be Completed by the City of South Bend):
City Connection Fee $_______________________
System Development Charge is billed by the City at the time the application for service is filed.
Wastewater Survey for Nonresidential Establishments
Waiver of Remonstration to Annexation Agreement
Annexation
Requires System Improvements
(Note:
May require
industrial
discharge permit and pre-treatment
)
Public Works Authorized Signature: ___________________________________ Date: ______________
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By executing this Utility Verification Form, you hereby ac
kn
ow
ledge the stateme
nts contained herein are true and
accurate.
If the City later determines that you misrepresented any statement on this Utility Verification Form, you will
be charged the corrected City connection fee. You understand the requirements to connect to City utilities as set
forth under South Bend City Ordinance and agree to meet the requirements set forth above.
Property Owner or Representative Signature: ____________________________________________ Date: ______________
Property Owner or Representative Phone: ________________________________
Please submit
Utility Verification fee of $50
to:
City of South Bend/Public Works
Permit Office
227 W. Jefferson Blvd
South Bend, IN 46601
UVF Fee Paid Date: ______________
Check # ___________
Credit
Cash
SDCs Paid Date: ______________
C
heck # ___________
Cash
click to sign
signature
click to edit
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