Application for Sewer-Deduct Meter

Date: _________________________________

Owner’s Name: ________________________________________________________________________

Service Information: 

                   Account Number:  ________________________________

Address:  _________________________________________________________________

                       City:  ______________________________________________  State:  ________________

                        Zip:   ________________________  Phone:  (_________) __________________________

Owner’s Information (If different than above):

                        Address:  _________________________________________________________________

                        City:  _______________________________________________  State:  _______________

                        Zip:  ________________________  Phone:  (__________) __________________________

I, the undersigned, have read and agree to the rules of Sewer-Deduct Meter as per section 1.14 D of the Village of Spencerville Water System Operating Rules.  I have also received a copy of these rules.

_____________________________________________________           _______________________

Applicant’s Signature                                                                                    Date

Social Security Number:  _____________________ - _________ - ______________________

__________________________________________________________________________________________

SPENCERVILLE WATER DEPT. USE ONLY:

Approved by:  _______________________________________________              ________________________

  Village Administrator                                                                      Date

Deduct-Meter Information:

Purchase Date:  ______________________                           Cost:  _____________________________

Installation Date:  _____________________                           Inspection Date:  _____________________

Deduct-Meter Account Number:  ____________________________________

Meter Serial Number:  _____________________________________________

Meter Register Number:  ___________________________________________

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