WATER SYSTEM CONNECTION PERMIT APPLICATION

Town of Fallsburg – Department of Public Works

P.O. Box 830

5410 State Route 42

South Fallsburg, New York 12779

(845) 434-6320

(845) 434-7972 Fax

NO PERMIT WILL BE ISSUED WITHOUT A UFPO CASE NUMBER

Date of Application:

Property Owner Name : (Please Print)

Mailing Address:

Telephone No:

Contractor Name: (Please Print)

Mailing Address:

Telephone No.:

Insurance Carrier & Policy No.:

SBL No.	Property 911 Address:
Building Permit Issues: Yes □ No □	Building Permit No.
Impact Fee Paid: Yes □ No □	In District: Yes □ No □
Size of Service:	Tap Required: Yes □ No □
Road Cut Permit Required: Yes □ No □
Road Cut Permit No. : Town □ County □ State □
Tap to be performed by: Town □ Contractor □
Tapping Contractor: (please print)
Contractor Address:
Contractor Telephone:	Contractor Cell Phone:
Date work is to begin:

UFPO Case No.
Water System Connection Permit No.
Date Issued:	Issued By:
Tapping Fee:	Inspection Fee:
Method of Payment: Cash □ Check □ Check # Money Order □ Money Order #

The UNDERSIGNED hereby agrees to do all specified herein and in full compliance with the Town of Fallsburg specifications for road cuts. The PERMITTEE further agrees not to alter same unless such alterations are submitted to and approved by the Town of Fallsburg. The OWNER and CONTRACTOR also agree, if granted this permit, to hold the Town of Fallsburg harmless from any and all liability for any work done under the granting of this permit or otherwise arising from the construction and restoration of the road cut, and CONTRACTOR will defend the Town of Fallsburg from any action, suits and or claims brought against the Town of Fallsburg.

Ø It is the responsibility of the Property Owner and or Contractor to contact the Underground Facilities Protective Organization (UFPO), 1-800-962-7962, to obtain a case number. The case number must be indicated at the top of this page. No Permit will be issued by the Town of Fallsburg until a UFPO Case Number in included on the Permit Application.

Property Owner Name: (Please Print)

Property Owner Signature:

Contractor Name: (Please Print)

Contractor Signature:

Ø This application must be signed by both the Property Owner (s) and the Contractor before the permit will be issued.

A RED Municipal Service Connection Permit will be issued upon approval of this application. This Permit must be displayed at the job site until all work has been completed, inspected and approved.

This Page Must be Read and Initialed by the Property Owner

REGULATIONS

All excavation for the water tap shall be made by the owner at the owner’s expense, and shall be dine under the supervision of the Water Department.

Where the excavation crosses or borders a County or State road, a permit from the appropriate agency must be obtained and attached to this application. For County roads contact the Sullivan County Department of Public Works, Sullivan County Government Center, 100 North Street, Monticello, New York 12701. For State roads contact the New York State Department of Transportation, East Broadway, Monticello, New York 12701.

All water taps up to and including two (2) inch size are to be made by the Town of Fallsburg Water Department. The allowable size of tap will be determined by the Town Engineer. Taps of a size larger that two (2) inches can be made only by an approved contractor experienced in this work, upon application.

Water Line Materials:

All water lines between to curb stop and the water meter are to be either Type “K” copper tubing or ductile iron pipe.

Backfilling:

The trench shall be backfilled with pipe sand for a minimum cover depth of one (1) foot above the top of the tubing or pipe. Backfilling shall be performed under the supervision of an inspector form the Water Department.

Curb Boxes and Valves:

Curb boxes and valve shall not be installed in driveways or sidewalks, A minimum of five (5) feet of horizontal separation shall be maintained for the edge of driveways, sidewalks, buildings, decks and or any other permanent structures.

Precautions During Construction:

The property owner and or contractor shall provide and utilize all appropriate work zone safety equipment. This equipment shall be in place prior to the beginning of construction and shall remain in place until all construction is completed, inspected and approved.

Property Owner Initials:

Town of Fallsburg - Residential

Basic Water Meter Installation Diagram - ⅝ x ¾, ¾ and 1” Meters

Notes: 1. Meter and Pressure Reducer should be installed in a horizontal position if at all possible

2. Pressure reducer should be a Watts U5b, 25AUB or equivalent

3. Backflow Preventor should be a Watts Series 7 or equivalent

4. Meter ends will be supplied by the Town

5. Spacing between meter ends – ⅝ x ¾ and short ¾ = 7 ½”, Full ¾ meters = 9”, 1” meter = 11”

6. Indicates the direction of flow from the street to the house

7. Contact the Water Department upon completion of the installation for inspection and connection of a remote reading device.

18” Minimum Spacing Distance

Meter Ends

Town of Fallsburg

Basic Water Meter Installation Diagram – 1-1/2” and 2” Meters

Notes: 1. Meter and Pressure Reducer will be installed in a horizontal position

2. Pressure reducer and back flow prevention device will be approved by the Town Engineer prior to installation

3. Meter ends (flange or screw) will be supplied by the Town

4. Spacing between meter ends – 1 ½” meter (screw 12 ⅝”, flange 13”), 2” meter (screw 15 ¼”, flange 17”)

3. Indicates the direction of flow from the street to the building

4. Contact the Water Department upon completion of the installation for inspection and connection of a remote reading device

18” Minimum Spacing Distance

Meter Ends