INDIAN HILLS WATER DISTRICT WATER LICENSE (TAP) APPLICATION                                                         

Date received by the IHWD___________

Time :____________

Owners Name(s): _______________________________________________________

Current Mailing Address: ___________________________________________________

                                                                                                                                                               

Telephone: Home:__________________________Work:_______________________

 E-Mail:                                                                          Best time to call:                                

This application must be for a property within the Indian Hills Water District. In order for this application to be accepted, a copy of the most recent Jefferson County tax statement must be attached and list the IHWD in the Tax Authority column.

Street address where water tap will be located: _____________________________________

Copy of County Property Tax Statement attached?    Yes   No 

Is there an existing  building on the property?    Yes   No 

What is the building used for?   Residence     Business    Other:___________________

Details:_______________________________________________________________________________

How many people reside (or will reside) at this property? ___________

Is there an operating well on the property?   Yes   No 

Is this an application for a hardship tap?   Yes   No 
(If yes, Please complete the Hardship Questionnaire)

If there is an existing well has it been tested for:  Production?   Quality?  

Details:_____________________________________________________________________________

A deposit of $100 is required.

Please sign below indicating all information on this application is correct and that, if approved, use under the license for the tap must be as limited and defined by the Rules and Regulations of the Indian Hills Water District. (a copy of the rules and regulations are available on this web site)

Signature:________________________________________________

Date: