serviceability application

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SERVICEABILITY APPLICATION
Please complete this form prior to the issuance of a Water & Wastewater Service Connection Permit to ensure the property is serviceable. A permit
will be issued once the financial securities have been paid as outlined in Section S.4 of the returned form.
Indicate how you would like to receive completed form? (Circle One): Mail / Email / Fax
S.1 - Applicant Information:
Applicant Name: __________________________________________
Phone Number: ______________________________________________
Mailing Address: __________________________________________
Fax Number: ________________________________________________
City:_____________________________________________________
Email: ______________________________________________________
Postal Code: ______________________________________________
S. 2 - Site Information (to be serviced):
Roll Number of Property: __________________________________
Property Frontage Length: _____________________m or feet (please circle)
Location/Address of Proposed Service(s): ____________________________________________________________________________________________
Service Connection Requested (Circle One/Both): Water / Sanitary Sewer
Water Service Size Required (Circle One): ¾ inch / 1 inch / other: __________
Fire Suppression Required (Circle One): Yes / No
Intended Property Use (Circle One): Residential / Multi-Residential / Commercial / Industrial
Is This Request A Result Of Any Planning Process ie Site Plan Approval or Severance? (Circle One): Yes/ No
File Number_____________
Is the Property Currently Serviced? (Circle One): Water: Yes / No
Sanitary Sewer: Yes / No
Office Use Only (Municipal Service Center/Building Department)
Date Received: __________________
Receipt of $100 application fee:
CKL Employee Initials: ____________________
For office use only (Public Works – Water & Wastewater)
Title: Serviceability Agreement
Document #: Admin_02 Form
Date: July 16, 2015
Uncontrolled document when printed.
Revision: 1
S.3 - Site Layout
Please mark where services should be installed including location of building, driveway and any other pertinent infrastructure (hydrants, manholes etc.).
Please note that water and sanitary sewer services must meet separation distances as outlined below. If application pertains to a planning process please attach
with approved site plan documents
Legend
Work is not to take place beyond limits shown without additional locates.
NOT TO SCALE
W
Watermain (W/M)
N
Water Valve
Water Service (W/S)
Hydrant
Yard Hydrant/
Blow -off
Sew er Service
Sew er Main
S
Manhole
Hydro Pole
Fence Line
Xx
Minimum Separation Distances
Single Family, Semi-detached, Duplex Lots
 Water service connections, where not impacting a driveway shall be installed at the mid-point of the frontage and to the right of the sanitary
connection.
 Water service laterals shall be laid with a minimum 2.50m horizontal separation and 0.5m vertical separation from any sanitary sewer lateral.
 Water service laterals shall not be installed within a driveway.
 Water and sanitary sewer service laterals shall be set back from side property lines a minimum of 1.2m
For office use only (Public Works – Water & Wastewater)
Title: Serviceability Agreement
Document #: Admin_02 Form
Date: July 16, 2015
Uncontrolled document when printed.
Revision: 1
S.4 – Fee Structure
Office Use Only (Public Works – Water & Wastewater)
The information below reflects that obtained from as-built drawings and/or site investigations and verification, it is the responsibility of the applicant to
field verify. Quotes are only valid for 90 days from the date of approval below. Any rock or frost breakage will be included in the quote based on at a
rate per cubic metre. A Water & Wastewater Connection Permit must be obtained through the City’s Water and Wastewater Department after the fees
listed below are collected by the City’s Building Department. A contractor will not be hired for the installation of the services until Connection Permit is
issued and the fees paid. All persons who require water or sanitary sewer service connection in relation to a property shall submit this Serviceability
Application to the City with a minimum of ten (10) business days to determine if subject property is serviceable.
General Information
Watermain/Sanitary Sewer Main Available at Frontage
of Property:
Capacity Available:
Yes
Water
No
Yes
Sanitary Sewer
No
Yes
No
Yes
No
Additional Fire Suppression Required:
(ie. Private hydrant or sprinkler system)
Water Fire Flows Available in Service Area:
Yes
No
N/A
Yes
No
N/A
Costs – Section A
Water
Account # (office use)
Connection/Inspection Fee
Connection Installation Fees (Contractor’s Quote –
excluding HST)
HST (ITC)
Frontage
Fee
Sanitary Sewer
Account # (office use)
$250
1-1-9982-1225
Fee
$250
1-1-9982-1225
$200/m for water (max 16 m-residential, 30 m – ICI)
$250/m for sanitary sewer (max 16 m – residential, 30 m – ICI)
Water Meter Fee
Total
Grand Total – Section A
For office use only (Public Works – Water & Wastewater)
Title: Serviceability Agreement
Document #: Admin_02 Form
Date: July 16, 2015
Uncontrolled document when printed.
Total
Revision: 1
Costs – Section B
Storm Sewer
Account # (office use)
Connection Installation Fees (Contractor’s Quote –
excluding HST)
HST (ITC)
Fee
1-1-9982-1225
Total
Grand Total (Section A + Section B):
Approved By: _____________________________________________
Date: _____________________________________________
Notes:________________________________________________________________________________________________________________________
For office use only (Public Works – Water & Wastewater)
Title: Serviceability Agreement
Document #: Admin_02 Form
Date: July 16, 2015
Uncontrolled document when printed.
Revision: 1
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