Start New Service - Pine Grove Community Service District

Pine Grove Community Services District - APPLICATION FOR WATER SERVICE

Date / Time *

LOCAL HOME/BUSINESS INFORMATION:

Property Owner's Name *

First

Last

Resident's Name *

First

Last

Street Address

Address Line 1

Address Line 2

City

State

Zip Code

Billilng Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

RESPONSIBLE PARTY'S CONTACT INFORMATION

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

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

Is this property a rental? If so please provide renter's name and phone number.

Renter's Name *

First

Last

Renter's Best Contact Phone

Pet Information

The District Water Manager may need to enter your property to read the metere. Do you have a pet he/she should be aware of? *

If YES, what type and how many?

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

I 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. Please note that payments for rentals are the responsibility of the owner of the property. If you are selling your property or have a renter moving, please contact us in advance for a final meter read and final billing. Your submission of this form is considered your signature of this document.

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.
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