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CITY OF WOODBURN PUBLIC UTILITY SERVICE APPLICATION Building Permit Number Receipt Number Meter Deposit Number Date ADDRESS WHERE STRUCTURE AND / OR SERVICES ARE TO BE LOCATED Applicant/Owner Phone Number Service Type ☐ Single-Family ☐ Commercial ☐ Industrial ☐Multi-Family (Number of Units) ☐Other ☐MFD (In Park) Type and Size of Water Service Requested ☐Domestic Size ☐Irrigation Size ☐ Fire Sprinkler Size The applicant agrees to abide by all rules, regulations, ordinances, policies and specifications of the city relating to sewers, traffic, storm, water and parks as now exist and as hereafter are changed or amended. Signature of Applicant OFFICE USE ONLY Accepted and Approved by Date ☐Water Service Fee SDC Based on Meter Size Date Water Meter Installed Meter Deposit Domestic Meter # ID # SDC Charge Irrigation Meter # ID # Water Main Tap Fire Sprinkler Meter # ID # Installation Fee $ Sequence # Account # Meter Reading Manufacture Code ☐Sanitary Sewer Service Fee Residential Type ☐ per Dwelling Unit ☐ per Unit ☐per Bed SDC Charge SDC Based on Gallons Per Day (Peak Load) ☐Storm Sewer Service Fee Roof Area (sq. ft.) SDC Charge Concrete / Asphalt (sq. ft.) Tap Fee Total Impervious Surface (sq. ft.) ☐Traffic Impact Fee $ per unit, room, or other, multiplied by = Number of Units ☐Parks Fee Residential (All Housing Type) per unit, multiplied by units = Non-Residential per employee, multiplied by _________employees = 0