Acton Municipal Utility District

PERMIT PAGE     ONLINE APPLICATION FOR LAWN SPRINKLER CONNECTION

Please print or type

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Contractor Information

Date: __ __ / __ __ / __ __ __ __

Contractor License: LI __ __ __ __ __ __ __     Expires on:  __ __ / __ __ / __ __ __ __

We will need a copy of Plumbers license or Irrigators license to establish Contractor as a viable provider.

 

Contractor Name:  ________________________________________________________________

                          Phone:  (__ __ __) - __ __ __ - __ __ __ __

Company Name:  __________________________________________________________________ 

                        Phone:  (__ __ __) - __ __ __ - __ __ __ __

Comments:  ______________________________________________________________________

_________________________________________________________________________________

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Home Owner Information

Home Owner Name:  _______________________________________________________________

Home Owner Address:  _____________________________________________________________

                                Phone:  (__ __ __) - __ __ __ - __ __ __ __    

Comments:  _________________________________________________________________

_________________________________________________________________________

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Type of Control to be used:

_____  Reduced Pressure Principle

_____  Double Check Valve

_____  Pressure Vacuum Breaker

_____  Reduced Pressure Principle-Detector

_____  Double Check Valve-Detector

_____  Spill Resistant Pressure Vacuum Breaker

 

Manufacturer:  __________________    Model #:  ____________________    Serial #:  ___________________

Devise Located at:  _____________________________________________________________

 

• Test cocks need to be accessible for testing equipment. 
• Test cocks facing down or too close to meter or meter box will result in a failed test.
• Backflow Devise is to be installed to manufacturer recommendations and manufacturer's information to be left at site.

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Additional Comments or issues for Board Consideration:  _________________________________

_____________________________________________________________________________________   

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

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For Office use Only:

Account #:  __ __ __ - __ __ __ __ - __ __ Premise #:  __ __ __ __ __ - __ __ - __ __ __ __ - __ __               

Received on:  __ __ / __ __ / __ __ __ __      $25.00 Permit Fee  Ref Number: ___________________

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Copyright © 2004-2007 Acton Municipal Utility District
Last modified: June 28, 2010