2. Name*
3. Email Address*
5. Address*
7. City*
8. State
9. Zip Code*
11. Phone Number*
12. Parcel #
14. I understand that the connection assessment fee is:*

    1. 6" Storm Sewer Connection Fee - $1,100.00
    2. 12" Storm Sewer Connection Fee - $2,000.00
16. I am electing to not immediately pay this fee in full. I understand that this fee will be assessed to the property and show up as a special charge on my tax bill, payable over five (5) years with interest. The 2023 interest rate is 6.5% per year.
18. The fee will be assessed to this address:*
20. I also understand that there will be a $30 plumbing permit fee that must be paid at the time the permit is applied for.*

    1. Yes, I understand.
    2. No, I do not understand. (The permit will not be issued without the $30 permit fee paid.)
22. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
24. Electronic Signature*
25. Date and Time*
    Date and Time

    Date and Time
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field