New Service ID

Account #: ________________________

Premise #: ________________________

Cycle: _____ Route: ______ = Seq:<= span style=3D'font-size:10.0pt;line-height:150%;color:#999999'> _______=

3D"[AMUD

= Today’s Date: ____ / ____ / ____

Work Order #: ______________

= Start Service:<= span style=3D'mso-spacerun:yes'> ____ / ____ / ____

<= i>2001 Fall Creek Highway * Granbury, Texas 76049= &= nbsp; &nbs= p; (817) 326-4720 * (817) 326-2361 *= Fax (817) 326-5031

NEW CUSTOMER SERVICE – IN DISTRICT

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Service Address: <= /span>_____________________________= _____________________________________________ Granbury, Texas 7604___

    &= nbsp;           &nbs= p;            &= nbsp; Phase/Block #: _________________ Lot #: _________________   Subdivision: ______________________________

Mailing Address: <= /span>____________________________= _____________________________________________________________________

PRIMARY ON ACCOUNT

Last Name: = ____________________________= _________________ First Name: __________________________________ MI= : _______

Drivers License #: _____________________________________________ Drivers License State: ____________________________= __

Date of Birth: _____ / _____ / _____  &nbs= p; Home Phone: ( _______ ) ________ - _________ Work Phone: ( _______ ) ________ - ________

JOINT ACCOUNT INFORMATION         (By designating a Joint Customer you are allowing that person access to your account information.)

Last Name: = ____________________________= __________________ First Name: _________________________________ MI= : _______

Drivers License #: _____________________________________________ Drivers License State: ____________________________= __

Date of Birth: _____ / _____ / _____  &nbs= p; Home Phone: ( _______ ) ________ - _________ Work Phone:&nbs= p; ( _______ ) ________ - ________

□ Senior Exemption excludes those over 65 or on Social Security from paying late penalties.

Yes

No

<<<<= <

Please answer to the best of your knowledge.<= /p>

These questions are designed to help you understand your water and sewer system and to make sure we get you all information that is pertinen= t to your address..

<<<<= <

□

□

Do you have an irrig= ation system?

□

□

Do you irrigate from= lake, river or other water source?

&nbs= p;

&nbs= p;

       &nbs= p;     Specify: ___________= __________________

□

□

Do you have a well?<= o:p>

□

□

Do you have a septic= system?

□

□

Do you have a Grinde= r Pump Low pressure sewer system?

□

□

Do you have a custom= er cutoff valve at tap?

□

□

Do you have hose bib= vacuum breakers on outside faucets?

Water Connection Fee= s:

Meter Maintenance<= /o:p>

$ 30.00

Account Maintenance

$ 15.00

Refundable Deposit=

$ 75.00

Total Water

$ 120.00

After Hours Fee

TOTAL DUE:=

Check #: __________________

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THIS DOCUMENT MUST BE VAL= IDATED

ON LINE FORM

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AGREEMENTS: AMUD SERVICE – IN DISTRICT

1.&n= bsp;        The district agrees to provide water and or sewer to the customer, and customer agrees to purchase such service from the District in accordance wi= th all rules, regulations, rates and charges as existing or as amended from ti= me to time.
1.1.    The Customer agrees not to drill any water wells.

2.&n= bsp;        All water meters, taps and other facilities installed by the District= are for the sole use of the customer, who shall not transfer service from one property or owner to another, nor share, sell or sub-meter service to any o= ther person, dwelling, business or any other entity, under penalty of law.<= /o:p>

3.&n= bsp;        The District shall have the right to locate service facilities on the property of the customer at a point chosen by the District. The customer agrees to grant to the District an easement and reasonable access to District facilities for all installation, maintenance repair and removal purposes.

4.&n= bsp;        The customer shall install, at his own expense, a service line from t= he District meter or tap to the point of use, and shall hold the District harm= less from all claims for damage to real or personal property resulting therefrom= or caused thereby.

5.&n= bsp;        The District shall not be responsible for the repair or replacement of any real or personal property within utility easement or right-of-way damag= ed in the process of installation, repair, maintenance, or removal of any faci= lity of the District.

6.&n= bsp;        In the event of water shortage, the District may restrict usage in any manner deemed equitable by the Board of Directors.

7.&n= bsp;        No connection from the District water system shall be made to any typ= e of non-potable system except through an air gap.

7.1.=     The customer hereby consents to inspection by the District of all plumbing facilities at this service location at reasonable times to insure compliance with the TCEQ 290.44.

8.&n= bsp;        The District assumes no liability for a blockage or rupture of the se= wer main occurring as a result of the acts of third persons, acts of God or for= ce majeure and not as the result of the acts or commissi= ons of the District.

9.   &n= bsp;     All constru= ction shall be in accordance with the current General Development Policy and Construction Standards of AMUD. The District shall inspect all water facilities on the customer’s side of= the meter prior to providing service. The inspection is to prevent possible cross connection between potab= le (safe) water and any non-potable (unsafe) water.

9.1.   = A cut-off valve must be included in the customer service line within 12” of the meter.

9.2.   = A similar inspection will also be made of all se= wer facilities on the customer side of the tap.

9.3.    DITCHES IN WHICH SEWER AND/OR WATER SERVICE LINE= S ARE LAID CANNOT BE CLOSED UNTIL INSPECTED BY AMUD PERSONNEL. ARRANGEMENTS FOR COORDINATION OF T= HESE INSPECTIONS MUST BE MADE BY THE BUILDER OR OWNER, OR THEIR AUTHORIZED REPRE= SENTATIVES WITH A 24 HOUR NOTICE GIVEN TO AMUD.

10.   &= nbsp; You are her= eby notified that theft, conversion, or unauthorized appropriation of water belonging to AMUD is unlawful and violates AMUD Resolution 05-09-154 and §31.03 Texas Penal Code, the fine for which varies from $500.00 to $10,000.00 as set forth above. The applicable fine is due and payable at the AMUD Office at 2001 Fall Creek Highway in Granbury, Texas on or before the expi= ration of ten (10) days from the date of the citation.

11.      AMUD WILL NOT ESTABLISH SERVICE TO PREMISE IF SE= RVICE LINES ARE NOT INSPECTED.

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Primary Customer Signature

=

Joint Customer Signature

AMUD Representative

Service Address: <= /span>____________________________= ______________________________________________ Granbury, Texas 7604___

Last Name: = ____________________________= _________________ First Name: __________________________________ MI:= _______

Last Name: = ____________________________= _________________ First Name: __________________________________ MI= : _______

Today’s Date: _____ / _____ / _____

Yes	No		<<<<= < Please answer to the best of your knowledge.<= /p> These questions are designed to help you understand your water and sewer system and to make sure we get you all information that is pertinen= t to your address.. <<<<= <
□	□	Do you have an irrig= ation system?
□	□	Do you irrigate from= lake, river or other water source?
&nbs= p;	&nbs= p;	&nbs= p; Specify: ___________= __________________
□	□	Do you have a well?<= o:p>
□	□	Do you have a septic= system?
□	□	Do you have a Grinde= r Pump Low pressure sewer system?
□	□	Do you have a custom= er cutoff valve at tap?
□	□	Do you have hose bib= vacuum breakers on outside faucets?

Water Connection Fee= s:
Meter Maintenance<= /o:p>	$ 30.00
Account Maintenance	$ 15.00
Refundable Deposit=	$ 75.00
Total Water	$ 120.00
After Hours Fee
TOTAL DUE:=

=	=	=		=
Primary Customer Signature	=	Joint Customer Signature		AMUD Representative