application-form-test - Pine Grove Community Service District

Pine Grove Community Services District – APPLICATION FOR WATER SERVICE

Requested Date & Time for Start of Service *

Date

Time

Property Owner's Name *

First

Last

Resident's Name *

First

Last

Property Address *

Address Line 1

City

State

Zip Code

Billing Address *

Address Line 1

City

State

Zip Code

Email *

ALTERNATE CONTACT INFO

Name

First

Last

Relationship to Property Owner

Enter the relationship with the property owner. If you are the property owner, enter “Self”.

Home Phone

Work Phone

Cell Phone

Pet Information

The 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? *

Is there a well or secondary water source on the property? *

Yes
No
Not Sure

I agree to the terms and conditions of the Rules and Regulations/Water Code of the Pine Grove Community Water Services District. A copy of the Rules and Regulations are available at the Rules & Regulations Page. 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 *

First

Last

Please type your full name to accept the terms.

Water Company Use: Meter Connection # ______________ APN:________________________________ Billing Acct# _________________ Date Received:__________________

Name