Application For Water or Waste Water Services

2. 

6. APPLICATION FOR WATER OR WASTE WATER SERVICE

   **MUST RETURN IN PERSON WITH PHOTO ID**

   **MUST RETURN IN PERSON WITH PHOTO ID**

8. System

10. Parcel #*

    If your parcel number is unknown, look it up online prior to filling out this form.

11. Phone #*

13. Legal Owner*

14. Cell #*

16. Address*

17. Fax #*

19. City*

20. State*

21. Zip Code*

25. IF OCCUPANT OTHER THAN OWNER, LETTER FROM OWNER AUTHORIZING INSTALLATION/BILLING TO BE SENT TO OCCUPANT MUST BE ATTACHED. CURRENTLY ONLY CHECK, CASH, CASHIER CHECK OR MONEY ORDER ARE ACCEPTED FOR PAYMENT.

27. Occupant*

28. Phone #*

30. Address*

31. Cell #*

33. City*

34. State*

35. Zip Code*

37. Mailing Address*

39. Structure*

    1. Apartment
    2. Commercial

    1. Duplex
    2. Industrial

    1. Single Family

41. Signature of Owner / Occupant*

    *Must be signed by hand.

42. Date*

44. Amount Received

    N/A

    N/A

45. Received By

47. NOTICE: COST OF INSTALLATION IS NOT COVERED BY PERMIT FEE.

    Installation cost will be billed when charges have been finalized.

    Installation cost will be billed when charges have been finalized.

51. The following information is required by the Federal Government in order to monitor compliance with Federal laws prohibiting discrimination against applicants seeking to participate in this program.

    <BR><BR>You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in anyway. <BR><BR>However, if you choose not to furnish it, we are required to note the race/national origin of individual applicants on the basis of visual observation or surname.

    
    
    You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in anyway.
    
    However, if you choose not to furnish it, we are required to note the race/national origin of individual applicants on the basis of visual observation or surname.

53. Ethnicity

    1. Hispanic or Latino

    1. Not Hispanic or Latino

55. Race

    1. American Indian / Alaskan Native
    2. Asian
    3. Black or African American

    1. Native Hawaiian or Pacific Islander
    2. White

57. Sex

    1. Male

    1. Female

59. This institution is an equal opportunity provider.<BR><BR> Esta institucion es de oportunidad igualada.

    This institution is an equal opportunity provider.
    
    Esta institucion es de oportunidad igualada.

Leave This Blank:


62. Print Only

* indicates a required field