City of West Branch
121 North 4^th Street West Branch, MI 48661
(989) 345-0500
(Please print, complete & return to City Hall at address listed above)
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Water Tap Application
(code of ordinances chapter 52)

Date: ______ /______ /___________ Phone #: (           )               -

Applicant's Name: _________________________________________________________

Owner's Name: ___________________________________________________________

Service Address: __________________________________________________________

Resident:_______________ Commercial: _______________ Industrial: ________________

Size of Water Line: _________________________________________________________

Are There Any Existing Wells on the Property: Yes _____ No _____

If the answer is yes, please notify District Health Department # 2 when the well has been properly plugged in accordance with Public Health Code, Act 368, P.A. 1978, Part 127.

                                                                           ___________________________________
                                                                                             Applicant's Signature

For Office Use Only

Amount Paid: _________________________
Date:________________________________
Inspected: ____________________________
Existing Well Plugged: Yes _____ No ______

If there is an existing well, send copy of application to District Health Dept. # 2.