Owner/Applicant

Name:*

Mailing Address:*

City:*

State:

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Zip:*

Daytime Phone:*

Service Location Information:

Property Address:*

Utility Account No.:*

Reason for Appeal:

(Check all that apply and attach documents and descriptions as indicated)*

Inaccurate Impervious Area Calculation-Owner shall provide a copy of a survey or site plan created within the past 12 months, indicating area in square feet of all impervious surfaces on the parcel. All measurements are subject to verification by staff. Impervious Area Removed from Site-Owner shall provide a description of the structure or area modified. Please provide a map or site plan if possible.

Other

Appeal Description and Documentation:

Describe the conditions as indicated above. Use the space provided to describe the areas in handwritten or 12 point font typed. Appeals missing required information will be returned to the applicant without review. Attach any required documentation (plats, surveys, photos, etc.) or additional pages as needed.*

Certification:

I certify that the above information contained in the application is, to the best of my knowledge, correct and represents a complete and accurate statement. By signing below, I agree to allow staff or inspector on site to review and verify the above information (if needed).

Signature: ______________________________________________________________

Printed Name:*

Date:

CITY OF WEATHERFORD USE ONLY

Date Received: ________________ Reviewed by:_______________
___Insufficient Information ___ Approved ___Denied ___Adjusted ___Other

Impervious Area/Lot Size: Before Review_______________ After Review_______________
Fee: Before Review _______________ After Review_______________
Notes: _____________________________________________________________________________________________
__________________________________________________________________________________________________

Date send to UB: __________________ Date determination sent to Applicant: _______________