PORTSMOUTH WATER AND FIRE DISTRICT

WATER MAIN EXTENSION APPLICATION

Date: _______________________________________________________________________________

Applicant's Name: ____________________________________________________________________

Address: ____________________________________________________________________________

Contact Person: ______________________________________________________________________

Project Name: _______________________________________________________________________

Project Location: _____________________________________________________________________

Assessor's Plat: ____________ ____________

Assessor's Lots: ____________ ____________

____________ ____________

Property Owner's Name: ______________________________________________________________

(if other than applicant)

Number of Potential Connections:

Single Family ____________

Duplex ____________

Commercial* ____________

Industrial* ____________

Other* ____________

* Attach engineer's statement of estimated water demand, site plan and requested service size for each

connection.

______________________________________________ _______________

Applicant's Signature Date

..........................................…………................……………………………………………………………….

Approved by Administrative Board _________________________

Date

Conditions: __________________________________________________________________________

____________________________________________________________________________________