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2. APPLICATION TO CONNECT TO PUBLIC WATER AND/OR SANITARY SEWER MAINS
4. Applicant:
6. Property Address:
8. Mailing Address:
10. Telephone #:
12. Proposed Use:
13. Site Plan#, if applicable:
16. Zoning Location Permit Application #:
18. Requested Action (check all that apply):

    1. Connection to Public Water System
    2. Connect to Public Wastewater (Sewer) System
20. Requested Meter Size (Except Single-Family Residence)
22. Address
24. City
25. State
26. Zip Code
28. I/We, the owner(s) of the above listed property, do hereby request a permit to connect to the water and/or wastewater treatment works of the Town of Middleburg, Virginia as identified above. In order to assess my request, I/We have provided the following information as an attachment to this application.
30. A. A plat of the property accurately showing all existing water and sewer mains and easements in relation to the property, including off-site improvements (Exhibit A).
32. B. Plans and specifications covering all work proposed to be performed under this permit (Exhibit B), to be reviewed and approved by the Town Engineer.
34. C. Zoning Location Permit Application in accordance with the Zoning Ordinance.
36. D. Completed Business Utility Form.
38. E. The name, address and contact information for any person or firm who will perform the work covered by the permit:
40. In consideration of the granting of this approval, I/We agree:
42. 1. To accept and abide by the provisions of the Water Ordinance and/or Sanitary Sewer Ordinance of the Town of Middleburg and the Town's Supplemental Water f& Sewer Regulations and all other pertinent Town, County, State or Federal ordinances or regulations.
44. 2. To install all facilities in strict accordance with the approved plans and at my expense.
46. 3. To pay the water and sewer connection and availability fees for the connection(s) as set by the Town Council.
48. 4. If the water and/or sewer lateral extends beyond my property in order to make the connection to the main, to assume liability for any and all claims arising out of or in connection with damages to the property to be served by the facilities; to other properties and to the facilities of the Town incurred by reason of the extension, operation and use of the facilities.
50. 5. If extension of a water and/or sewer lateral is necessary beyond my property to make the connection, to furnish the Town with detailed plans, prepared and sealed by a certified professional engineer, showing all utility lines and facilities (new and existing) as built and all easements, if necessary, as recorded.
52. 6. To make no water and/or sewer lateral connection(s) without first obtaining written permission therefore as required by the Water and Sewer Ordinances of the Town.
54. 7. If a non-residential use, to provide a Business Utility Form to calculate the specific number and size of the taps.
56. 8. To provide a separate water and/or sewer lateral for every building on the property in conformance with Town Code Section 83.1-5.
58. 9. To pay for any and all charges for the use of the public utilities of the Town when and as due until such time as the property owner arranges for the transfer of the utility service accounts entered in the property owner's name to the name of the person or persons who acquired title to the above-described property. In order to effectuate the transfer of such accounts, the property owner agrees to arrange for the processing of such transfers at the time of sale, rental or lease of each parcel of the above described property.
60. Signature of Applicant(s)
61. Date
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67. 1. Receive an email copy of this form.
68. Email address

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69. Submit

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