Download water fill permit application

WATER FILL PERMIT APPLICATION
Key FOB: $45, including $25 refundable deposit for working FOBs
OWNER INFORMATION
Name
Address
Email
Phone
Property Address
Are you the Occupant of the Property? ☐ Yes ☐ No
OCCUPANT INFORMATION (if different than Owner)
Name
Address
Email:
Phone
TERMS OF BULK WATER FILL STATION WATER SUPPLY PERMIT
I understand and agree that I am fully responsible for the safe and proper use of the Bulk Water Fill Station, and
that I am expected to read and comply with the operating instructions and directions provided at the Bulk Water
Fill Station. I understand the key FOB supplied for use is the property of the District of Mission.
I further agree that any and all water taken from the Bulk Water Fill Station is for personal use and will not be
offered for sale or transported to properties other than the address assigned to the permit. I agree to use a
properly disinfected tank (as set out by the Fraser Health Authority in their document Guideline for Bulk Water
Hauling that is available on the District’s website), to transport any and all potable water obtained at the District
Bulk Water Fill Station. The maximum quantity of water to be drawn from the Bulk Water Fill Station weekly shall
be four thousand litres (4,000 L) daily, or ten thousand five hundred litres (10,500 L) weekly.
I further agree to release, indemnify and save harmless the District against any and all claims, actions, costs,
expenses, losses and liabilities of whatsoever kind and by whomsoever brought against the District arising out of or
in any way due or relating to the granting to me of this Bulk Water Fill Station Permit, or my compliance or noncompliance with the terms of this permit.
Signature
Date
Please submit completed application form and fee to: District of Mission - Finance Department, 8645 Stave Lake Street, Mission, BC V2V 4L9
Applicant’s driver’s licence or most recent utility bill must be available to present to staff as proof of address.
FOR OFFICE USE ONLY
Date
Receipt No.
☐ Permission is hereby granted to the Applicant for use of Residential Water Supply.
☐ Applicant not connected to municipal water system.
Property Roll No.
Key FOB No.
Permit Approved by
cc: Public Works, Finance Department
Signature
File: 09-4520-20-05 / MAIS (22-03)