APPLICATION FOR WATER SERVICE

DATE OF SER.:____________

______________________                       ________________________                 Homeowner  / Tenant  / Realtor

 Account # - Service ID #                      E-Mail Address                                                 Please circle one        

___________________________           ________________________              _____________________

Last Name                                                       First Name                                                  Middle Initial

_______________________________           ____________________________              ______________________                

Last Name (Spouse)                                       First Name (Spouse)                                  Middle Initial (Spouse)

___________________________           ________________________              _____________________

Service Address                                            City, State                                                      Zip Code 

___________________________           ________________________              _____________________

Mailing Address                                            City,  State                                                     Zip Code

___________________________           ________________________              _____________________

Home Telephone #                                         Cell Phone #                                               Work Phone #

____________________          _________________                         ________________                _____________________

Place Employed                             Reference Name                   Reference Phone #                   Social Security No.

Is there a well on property:       Yes           No          Double Check Valve:    Yes        No

The Undersigned hereby request utility service at premises designated above, and waives claims for damages resulting from running water originating from leaks, open faucets, etc. on such property, and agrees to hold Sutter C.S.D. harmless from any such damages.

I authorize Sutter Community Services District to give my landlord, if requested, information regarding the status of my utilities account (i.e. if my account is 30, 60 or 90 days past due.

_________________________________                                                                                   ____________        

Signature                                                                                                        Date                  

New Account Service Fee:    $12.00

Security Deposit:                   $40.00

FOR OFFICE USE ONLY

Meter I.D _______________      Meter Serial No. _________________      A. P. No_________________

Homeowner:__________________________________________________________________

                           Name                                                 address                                                   Phone#

Note:_________________________________________________________________________

______________________________________________________________________________

            DATE:  _____________________

            Dear Customer,

            The backflow prevention assembly that is installed at the residence listed

            Below is due for annual testing, as required by the Sutter C.S.D. Ordinance

            No. 92-03 and the State of California Department of Health Services.

            The district provides the valve testing service.  The testing fee is $34.50, but

            For your convenience, the cost will be $2.87 monthly and will reflect on your

            Monthly bill.  Please sign the authorization form below to give authorization

            For the billing and testing of the device.

                                                                        Thank you,

David Guerin

                                                                        Backflow Prevention Administrator

            I hereby authorize Sutter C.S.D to test the backflow prevention assembly

            That has been installed at my residence.  I understand the annual fee of

            $34.50 is reflected on my monthly bill at $2.87 under “valve test”, for my

            convenience.

                                                                        Signed_____________________________