City of Port St Lucie
Utility Systems Department
PSLUSD
900 SW Ogden Lane, Port St Lucie, FL 34983
Email: [email protected]
Phone (772) 344-4320
Temporary Water Meter Permit Application for Service
Type of Meter Needed:
Jumper Assembly
Hydrant Assembly
Applicant's Printed Name
Telephone
Billing Address: Street, City, State & Zip
E-mail
Meter Size:
5/8 x 3/4"
1"
2"
3"
4"
6"
8"
10"
Street Address
Lot
Block
Section
Nearest Cross Street
****Attach an 8 1/2" x 11" map of proposed location of fire hydrant or jumper assembly.****
Terms of Agreement:
acknowledges:
As a representative of
, the undersigned
1. Responsible for leaving the construction meter assembly in the assigned location and for displaying
the permit tag.
2. Responsible for any and all damage to private property that may result from utilizing the back-flow
assembly.
3. Responsible for any property damage, including, but not limited to, the PSLUSD meter and backflow
assembly and/or PSLUSD water distribution system due to negligent use of the backflow assembly, theft
or vandalism.
4. In the event of loss, theft, or vandalism, the refundable deposit is forfeited.
5. Responsible to pay for all related metered water consumption.
Permit Time Extensions: The permittee is responsible for monitoring their permit's expiration date. A
permittee may request time extensions in 180-day increments. A permit extension fee applies.
Meter Relocation: The permittee may request the relocation of a specific permitted temporary meter if it
is to be relocated to another location within the boundaries of the development for which it originally
provided service. A relocation fee applies.
New Meter
Meter Relocation
Time Extension
New Expiration Date:
Date:
Signature:
PSLUSD Egnineering Use Only
Cross Connection Use Only
Customer Service Use Only
Project Name:
Permit Date:
Amount Received:
Project No.:
Permit No.:
Receipt No.:
Permit Expiration:
Date:
Approved:
Effective 01/23/17
Date:
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PSLUSD Doc. No. 118