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2. 
3. APPLICATION FOR ACCEPTANCE OF PORTION OF PRIVATE LATERAL BY TOWN
5. Name
6. Email Address
8. Address
10. City
11. State
12. Zip Code
14. Phone Number
15. Fax Number
17. Property Address (if different than mailing)
19. Requested Action (check all that apply)

    1. Acceptance of portion of private water lateral (from public main to the meter)
    2. Acceptance of portion of private sewer lateral (from public main to property line)
23. I/We, the owner(s) of the above-listed property, do hereby request that the Town accept a portion of the private water/sewer lateral as indicated above, serving our property for repair and maintenance. In order to assess this request, a plat is attached that shows the following information as an attachment:*

    1. The public main to which the lateral(s) is connected
    2. The lateral(s) from the public main to the building served
    3. Any meters and/or clean-outs associated with the utility service
    4. All property boundary lines over which the lateral(s) traverse
    5. The identification of all property owners for all properties over which the lateral(s) traverse
    6. In the case of a water lateral, the exact length of the water lateral from the public main to the water meter
    7. In the case of a sewer lateral, the exact length of the sewer lateral from the public main to the property line
25. Attach Plat*
27. In consideration of the granting of this application, I/We covenant and agree to the following:*

    1. The water and/or sewer lateral has been installed in accordance with all applicable specifications as adopted by the Middleburg Town Council;
    2. The water and/or sewer lateral is in an acceptable condition as determined by the Town Administrator;
    3. We authorize the Town Administrator or his authorized representative to inspect the lateral(s) to confirm it is in an acceptable condition;
    4. For water laterals, the water meter is located within a public right-of-way or within 5 feet of the property line and is not located in a building/structure
    5. For sewer laterals, the clean-out is located at the property line
    6. The length of the water lateral from the public main to the water meter is no more than 35 feet;
    7. The length of the sewer lateral from the public main to the property line is no more than 35 feet
    8. The water and/or sewer lateral does not cross a third parties' property
    9. I/We have met all of the conditions of the Town Code and Water/Sewer Lateral Maintenance Policy;
    10. To reimburse the Town for all expenses incurred in investigating this application;
    11. If the application is approved, to provide the Town with a public access easement (as approved by Town) and to be recorded at my expense;
    12. I/We verify the water and/or sewer lateral is not part of a privately maintained system that is the responsibility of multiple owners or an HOA;
    13. I/We understand that we will be responsible for any maintenance of laterals due to inappropriate disposal or activities on the part of the owner or occupants.
31. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
33. Electronic Signature
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

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