APPLICATION FOR SEWER SERVICES
OUTSIDE OF CITY BOUNDARIES
To: City of San Bernardino
Economic Development - Real Property Section
290 N. "D" Street - 3rd Floor, San Bernardino, CA 92418 (909) 384-5366 / [email protected]
This application is hereby submitted to the City of San Bernardino, to initiate proceedings for the connection to the City Sewer System from my property, which is located outside the boundaries of the City of San Bernardino pursuant to established City policies, a copy of which I have received and read, and Government Code Section 56133. I understand that a $1,300.00 non-refundable processing fee is due at the time this application is submitted. I further understand that prior to the City submitting an application to the Local Agency Formation Commission (LAFCO), I will be required to deposit any applicable LAFCO fees with the City ( or to be paid directly to LAFCO). Additional LAFCO fees may be due at the conclusion of the proceedings, which I will be required to pay. I may request a waiver of these fees from LAFCO, based upon an immediate health and safety issue. In the event that the waiver of all or a portion of the LAFCO fees is granted by LAFCO, the waived amount will be refunded. I also understand that I will be required to execute an "Irrevocable Agreement to Annex" in the event that my property may be subject to Annexation into the City of San Bernardino at some future time, if this application is approved. I further understand that sewer capacity and hook-up fees to the City will be due prior to permit processing. This application is being submitted with the understanding that approval ls not guaranteed.
Please submit this application with proof of ownership (Copy of Deed, Title Policy, etc.) along with ~:::::ttf:%:&2a:,l6~!Ydftff¥9
Assessor's Parcel No(s): {:)2_ I:, 2/ r/f/C>(XJO Tel. No.:S~.2 -157., 859,r ( ) Existing Development: ~
1tf Residential (Single Family). No. Bedrooms:~
1~ Residential (multi family). Describe: ___ _
11 New Development:
[] Residential (Single Family) No. Bedrooms __
[] Residential (multi-family). Describe:. ___ _
[] Commercial/Industrial. Describe: _____ _ [] Commercial/Industrial. Describe:. _____ _ Note: For ne~ development and/or additions, please provide a copy of the site-plan along with a copy of development permit application, if any, filed with the County of San Bernardino.
Additional Comments: ____________________________ _
[] I request a waiver of LAFCO fees based upon the following health and safety urgency:
Date: y .... } -25 /Pl~~-----
Signature(s)
FOR CITY USE ONLY
Received on:. _________ by:. _________ Receipt No.: __________ _ Nearest sewer main:. ________________________________ _ CITY FEES:
Filing: $ 1.300.00 Comments: ______________________ _
Capacity:
Connection:
Inspection:
TOTAL: $ ___ _
Rev. 12/2011