Commercial Connection Application

1111 W. Main St. Suite K

Greenfield, IN 46140

317-462-4469

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COMMERCIAL APPLICATION FOR WATER AND SEWER CONNECTION

Builder	Phone
Builder’s Address
Lot Number	Development
Lot Address
Customer Name (If Known)

PERMIT INFORMATION:

Sump Pump Discharge to:
o Yes o No	o Ground Surface	o Storm Sewer	o Other
Roof Run-off, floor drains & sub-surface drainage to:
	o Ground Surface	o Storm Sewer	o Other
Cooling water or geothermal system discharge to:
	o Ground Surface	o Storm Sewer	o Other

Description of Facility
EDU Allocation/Estimated daily gallonage
No. of restrooms	No. of employees	Occupancy Date

WATER FEES (Checks payable to Gem Water Inc.):


Choose One Connection type:
Initial Connection For 3/4" ($800)		Amount Paid $______
Initial Connection For 1" ($1100)		Amount Paid $______
Initial Connection For 1-1/2" ($1500)		Amount Paid $______
Initial Connection For 2" ($3500)		Amount Paid $______
Initial Connection For 3" ($4000)		Amount Paid $______

In certain Instances additional fees may apply see Initial Water Connection Fee Structure

I hereby certify that I have the authority to make the foregoing application, that the application is correct, and that all construction of sanitary sewer and water lines will comply with all rules, regulations, standards, and specifications currently adopted by Gem Utilities Inc. and Gem Water Inc. I further certify that storm water (i.e. downspouts, sump pump, surface water drainage, etc.) shall not enter the sanitary sewers. I further certify that no connections of sewer and water will be made without inspection and approval of Gem Utilities Inc. and Gem Water Inc.

Signature of:

Builders Authorized Agent ________________________Date:________

Office Use Only:

Application Approved By: ________ Date _______

Sewer Inspec. Date: ____ By ____

Water Line Inspec. Date: ____ By _____

Water Pit Inspec. Date: _____ By _____