Non-Sewered Water Exemption Request Form

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Dept.of Environmental Management COUNTY OF HAWAII Wastewater Division NON-SEWERED WATER EXEMPTION REQUEST Service No. TMK: - - Address: I hereby request a non-sewered water exemption for the following water consumption: •Agricultural or Landscaping ❑ Swimming Pool •Ice-making Equipment ❑Cooling Tower ❑Washdown Facility ❑Other: I propose to install at my own expense an approved type of sub-meter in a location readily accessible for inspection. I have attached the plans of the system piping including product data and location of the sub-meter for Wastewater Division approval. If approved,I agree to the following conditions: 1. The water drawn through such sub-meter(s): ❑ will not be discharged into the sanitary sewage system. ❑ represents all water drawn on the property that may be discharged into the sanitary sewage system. 2. I will read the sub-meter(s)to coincide with the water bill cycle and I will submit the sub-meter reading(s)bi- monthly or monthly dependent on the water billing cycle,five days after receiving the Department of Water Supply water bill. I will also provide a copy of the water bill. 3. Right-of-Entry is authorized to the Wastewater Division for purposes of reading meters and conducting inspections at their discretion. 4. Depending on when the readings are submitted,the adjustment may be made in a subsequent billing period. 5. A minimum monthly charge shall be applicable and shall be equal to the current monthly rate at the time of the exemption period. 6. This exemption is non-transferable. I will notify the Wastewater Division of any changes in ownership or property use. 7. If the tamper-resistant seal on the sub-meter(s)is found to be broken,the owner shall replace the meter within 30 days. Failure to comply will result in the exemption becoming void and a new exemption request application will need to be submitted to the Wastewater Division. Completed Request should be returned to Wastewater Division, 108 Railroad Avenue,Hilo,HI.96720 AGREED: Signature(Applicant) Date Please Print Name Phone Signature(Owner,if different from Applicant) Date Please Print Name Phone APPROVED: Effective Date Wastewater Division Chief Date ATTACHMENT A