/

Water/Sewer

Connection Permit

City of Somersworth, New Hampshire
Water Division
One Government Way, Somersworth NH 03878
Telephone: (603) 692-9523 / (Office Use Only)
Permit #: ____-______Issue Date: ______
Map #______
Lot #
Site Address:
Property Owner: Phone:
Mailing Address: Cell #:
City: State: Zip Code: Email:
Contractor: Phone:
Mailing Address: Cell #:
City: State: Zip Code: Email:
Check all that apply for this property:
New Construction Single-Family Home Irrigation System City Water
Existing Structure Multi-Family Home Fire Suppression System Well
Change of Use Commercial Pool City Sewer
Industrial Septic
Description of work to be performed:
WATER CONNECTION / SEWER CONNECTION
FOR RESIDENTIAL UNITS:
Size of water line: ______
Backflow Device* required? Y / N . / FOR RESIDENTIAL UNITS:
Number of Bedrooms: ______
FOR COMMERCIAL / INDUSTRIAL UNITS:
Size of water line: ______
Backflow Device* required? YES . / FOR COMMERCIAL / INDUSTRIAL UNITS:
GPD Flow Volume: ______
Further information may be required to accurately calculate the sewer connection fee, depending on the type of use.
Permit must be entirely completed and the connection fees of $______must be paid in full before this permit will be approved and granted. Water and /or Sewer work shall not begin until permit is approved.
This application to connect to the City of Somersworth Water and/or Sewer System is made by the undersigned who agrees, as the authorized representative or owner and for future owners, to indemnify the City from any loss or damage that may directly or indirectly be occasioned by said connection to the system. The City of Somersworth in no case, assumes any responsibility or liability by reason of granting this permit. The applicant also understands and agrees that with the approval of this permit, and the completion of connection, a water/sewer account will be created or adjusted in accordance with the request of this permit. If the information provided by the applicant is incorrect, the applicant understands and agrees that there could be additional fees based on the fees outlined on the back-side of this application and in the ordinance. The undersigned further acknowledges that he/she is familiar with and agrees to abide by the City of Somersworth Water and Sewer Ordinances.
______
Authorized Signature Date / Return completed permit application to:
Somersworth Water Department
City Hall
One Government Way
Somersworth, NH 03878
______
Approved by: Date / Contact the Somersworth Water Department
to schedule Connection after approval.
603-692-9523
~~~ THIS SIDE TO BE COMPLETED AND CALCULATED BY THE UTILITY ~~~
based on fees outlined in the Water and Sewer Ordinances
*BACKFLOW DEVICES – A backflow device is a device or means designed to prevent backflow or backsiphonage.
·  ALL Commercial and Industrial Customers are required, according to regulation, to have one or more backflow prevention devices installed and shall assume the responsibilities as contained in the Somersworth Water Ordinance.
·  Residential properties with a pool, hot tub, Jacuzzi, or irrigation line are required to have a testable backflow device installed on the water service line.
·  An approved backflow prevention device must be installed according to the degree of hazard, if a backflow were to occur.
·  In cases of a high hazard threat, a Reduced Pressure Zone (RPZ) Device, or similar, is required.
·  In cases of a low hazard threat, a Double Check (DC), Pressure Vacuum Breaker (PVB), or similar, is required.
·  For more information regarding backflow prevention requirements, you may contact Somersworth Water Department at 603-692-9523. For more detailed information on backflow regulations, refer to the City of Somersworth Water Ordinance or contact the New Hampshire Department of Environmental Services.
WATER CONNECTION FEES per Somersworth Water Ordinance, Chapter 32
3/4" / 1" / 1.5" / 2" / 4" / 6" / 8"
$1,100.00 / $1,500.00 / $1,800.00 / $2,300.00 / $2,100.00 / $3,700.00 / $5,300.00
·  Contractor digs and supplies parts and equipment needed for digging and running line from main to property connection.
·  City taps the main, provides parts necessary for tapping, inspects line and installs meter. / ·  Contractor digs, supplies parts and equipment, taps main and installs meter.
·  City oversees tap and provides the meter.
Irrigation or Secondary Meter Installation
3/4 - 5/8" / 1" / 1.5" / 2"
$480.00 / $675.00 / $920.00 / $1,330.0
·  Includes Meter, Radio Transmitter, Direct Mount Kit, Adapters, Straight/Angle Valve, Dual Check Valve, and Labor.
/ Residential, Commercial and Industrial
Size of Line ( _____ ) Fee
Secondary Meters ( ____) Fees
Total Water Connection Fee / ______
______
______
SEWER CONNECTION FEES per Somersworth Sewer Ordinance, Chapter 8A
Residential
Number of Bedrooms
□ Betterment District ($250/bedroom)
□ Other Locations ($1800/bedroom)
Total Sewer Connection Fee / ______
______
______
______ / Commercial / Industrial
GPD Flow Volume
Divide by 75 gallons (GPD bedroom equivalent)
□ Betterment District ($250/bedroom equiv.)
□ Other Locations ($1800/bedroom equiv.)
Total Sewer Connection Fee / ______
______
______
______
______
Paid By: / Date Paid / Check Number / Rec’d By: / Calculated Fees
Total Water: ______
Total Sewer: ______
Total Fees Due:
______
NOTES:
Account # / District / Route / Walk Sequence / Date of Tap / Work Order #

Revised 08-2014 www.somersworth.com Page 1 of 2