Town of Salisbury Water & Sewer Access Fee Determination and Acknowledgment

Applicant Name: ________________________ Contact Phone No. __________________

Billing/Mailing Address: ____________________________________________________

Property Address: __________________________ Unit No.____ Map _____ Parcel _____

Current Property Use: _______________________________________________________

Proposed Project/Property Use: ________________________________________________

No. Sewer EQRs Assigned: ________ No. EQRs For Which Betterment Was Paid _______

Official Use Only

New EQRs (based on proposed property use) _____ How calculated _______________

No. EQRs For Which Sewer Betterment Was Paid _______

Water Access Fee (New EQRs less Betterment EQRs Paid times fee):

_______ less _______ times $4,258 = $___________

Sewer Access Fee (New EQRs less Betterment EQRs Paid times fee):

_______ less _______ times $3,080 = $___________

Town Official Signature: ________________________ Date: _________

Notes: __________________________________________________________________

I acknowledge receipt of this preliminary access fee determination and agree to pay the fees assessed upon installation of water and/or sewer service and receipt of a Certificate of Use and Occupancy, if applicable.

Applicant Signature: _____________________________ Date: _____________

Collector Use Only

Access Fee Paid: Water: ________ Date: _______ Sewer:_______ Date: ________

Collector Signature: _______________________ Date: _____________