West Iredell Water Company
P. O. Box 5607
Statesville, NC 28687
(704) 873-1658 – Phone
(704) 873-1655 - FAX
FIRE HYDRANT USE PERMIT
Permits are hydrant specific and are valid only for the calendar year in which they are issued. The permit fee is $25.00 per calendar year plus $10.00 per 1000 gallons of water used. Also, the West Iredell Water Company must be called in order to have a staff member on-site any time water is taken from a hydrant. If a West Iredell Water Company staff member is required to be on-site prior to 8:00 a.m., after 4:00 p.m., weekends, or holidays, then the permit holder will be billed for the WIWC staff member’s overtime at 1.5 times the staff member’s regular rate of pay. Each hydrant location MUST be listed on the permit. Monthly water usage reports must be turned in to the West Iredell Water Company Office no later than the 5th of each month for water used during the previous month. West Iredell Water Company requires backflow protection in the form of an approved 6” air gap or an approved and tested RPZ (reduced pressure zone assembly) on all tanker trucks and water tanks.
Contractors
Contractor name: ______
Specific construction project: ______
Mailing/Billing address: ______
Phone (____) ______FAX (____) ______
Truck/trailer License Number(s)______
Permit Fee $25.00
Individuals
Name: ______
Mailing/Billing address: ______
Phone (____) ______FAX (_____) ______
Truck/trailer License Number(s) ______
Permit Fee $25.00
INDICATE INTENDED USE: ______
PROPOSED HYDRANT USE LOCATION(S)– Example (Old Mountain Road at West Iredell
Circle)
______
Signature Requirements: This permit must be signed by an authorized representative of the Applicant as described herein. For a corporation, this permit shall be signed by a responsible corporate officer. A responsible corporate officer means a president, secretary, treasurer, or vice-president of the corporation in charge of a principal business function, or any other person who performs similar policy or decision-making functions for the corporation. For a partnership or sole proprietorship, this permit shall be signed by a general partner or the proprietor, respectively.
The signature releases West Iredell Water Company(and the applicant agrees to hold harmless and defend West Iredell Water Company) from any claims from any and all liability and losses for personal injury or property damage resulting from applicant’s use of a fire hydrant. This form becomes the official permit upon signature by the applicant and the General Manager of the West Iredell Water Company and assignment of a billing account number by West Iredell Water Company personnel. The permit holder MUST keep a copy of this permit in the vehicle used to withdraw the water. The permit holder is liable for any property damage and/or damage to the hydrant or infrastructure due to misuse or improper operation of the hydrant.
I hereby authorize West Iredell Water Company to inspect my water carrier/container, the hydrant use permit, and hook-up and/or backflow prevention assemblies. I have read the Fire Hydrant Use Procedure and understand that failure to comply will result in a penalty issued by the West Iredell Water Company of up to one thousand ($1,000.00) dollars per violation and/or an immediate suspension of privileges and closure of any account issued to the person in violation.
By signing, I certify that I am the applicant or an authorized representative of the applicant.
______
Applicant Title Date
Account Number: ______
______
General Manager Date Issued
West Iredell Water Company
(November 2007)