Please enable JavaScript in your browser to complete this form.Pine Grove Community Services District - APPLICATION FOR WATER SERVICEDate & Time *DateTimePlease indicate the date and time you'd like us to service the property.SERVICE LOCATION INFORMATION:Property Owner's Name *FirstLastRelationship to Property Owner *Select...SelfTenantSpouseOtherEnter the relationship with the property owner. If you are the property owner, enter "Self". Home PhoneWork PhoneCell PhoneResident's Name *FirstLastOther *Enter the relationship with the property owner.Property Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeBilling Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *PROPERTY OWNERS CONTACT INFORMATIONHome PhoneWork PhoneCell PhoneStreet Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeBilling Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeALTERNATE CONTACT INFONameFirstLastRelationship to Property Owner Select...SelfTenantSpouseOtherEnter the relationship with the property owner. If you are the property owner, enter "Self". Other *Enter the relationship with the property owner.Home PhoneWork PhoneCell PhonePet InformationThe District Water Manager may need to enter the property to read the meter. Is there a pet on the property he/she should be aware of? *YesNoWhat kind and how many? *Is there a well or secondary water source on the property? *YesNoI agree to the terms and conditions of the Rules and Regulations of the Pine Grove Community Water Services District. A copy of the Rules and Regulations are available at your request. If you are selling your property or have a renter moving, please contact us in advance for a final meter read and final billing. I understand that my signature below acknowledges my responsibility for all payments and charges applicable to the applied service(s) in accordance with the Pine Grove community Service District Rules and Regulations and serves as a signature of this document. Please note – payment for rentals are the responsibility of the Owner.E-Signature *FirstLastPlease type your full name to accept the terms.Water Company Use: Meter Connection # _________ APN:____________ Billing Acct# ___________ Date Received:__________________WebsiteSubmit
