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Utility Service Connection Application 1 I P a g e Date: Type of Request: New Water Connection New Sewer Connection New Fire Line Connection Repair Connection Property Address (Required): Subdivision: Parcel Number(s): Lot: Block: Property Zone: Property Owner Information: (Required) Name (first and last): Address: City: State: Zip Code: Phone Number: Email: Contractor Information: (Required) Company Name: Contact Name: Address: City: State: Zip Code: Phone Number: Email: License Number or Registered Contractor’s Number: Expiration Date: Engineering Firm: (Required) Company Name: Contact Name: Address: City: State: Zip Code: Phone Number: Email: (see page 2) ---PAGE BREAK--- Utility Service Connection Application 2 I P a g e REQUIRED FEES: Water Meter Fee: Water Connection Fee: Sewer Connection Fee: Road Cut Fee: Alley Cut Fee: Fire Line Connection Fee: $ Required Meter Install: Size of Water Meter: Quantity: Size of Irrigation Meter: Quantity: Fire Line Size: APPLICANT ACKNOWLEDGMENT & SIGNATURE I hereby certify that the information provided is accurate. I agree to comply with all city ordinances, state laws and regulations regarding water and sewer connections. I understand that all fees must be paid prior to approval and installation. Signature: Date: FOR CITY USE ONLY Application Received By: Date: Approved By: Date: Connection Fees Paid In Full: [ ] Yes [ ] No Work Order Issued: [ ] Yes [ ] No Scheduled Date: Notes: SIGN