New / Replacement Service            Split: Domestic            Split: Irrigation           Existing Well

     SERVICE   ADDRESS                                                                              CITY 

  INFORMATION TAKEN BY                                                                          DATE

    CUSTOMER / COMPANY NAME

 DAY PHONE                                          CELL                                                 FAX

    MAILING ADDRESS

EMAIL:

 CITY / STATE / ZIP 

    ON SITE CONTACT                                                               DAYTIME  PHONE

 FEDERAL TAX ID   OR    DRIVERS LICENSE  #    (REQUIRED)

    GOV’T AREA

 LOT #  OR  LEGAL DESCRIPTION

 SERVICE  RATE:      RES  /  COMM  /  INDUST      (CIRCLE ONE)

 SERVICE   SIZE :         .75”            1”           1.5”          2”        (CIRCLE ONE)

    DOMESTIC METER :     .75”            1”           1.5”          2”        (CIRCLE ONE)

    IRRIGATION  METER :     .75”            1”           1.5”          2”      (CIRCLE ONE)

    SUBDIVISION

  SITE  PLAN  ATTACHED  (WITH SERVICE ROUTE & ENTRY MARKED)

          (REQUIRED FOR ALL  NEW SERVICE  APPLICATIONS)

NOTE:  SITE PLANS / SKETCHES SHOULD INCLUDE FOUNDATION DIMENSIONS, AS WELL AS MEASURED DISTANCES FROM PROPERTY LINES, EDGE OF ROAD, ETC.

PLEASE USE THE AREA BELOW FOR SKETCHES, COMMENTS, ETC.