New Service ND

Account #: ________________________

Premise #: ________________________

Cycle: _____ Route: ______ Seq: _______

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 – NON-DISTRICT

<= /b>

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

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

Mailing Address: <= /span>____________________________= _____________________________________________________________________

PRIMARY ON ACCOUNT

Last Name: = ____________________________= _________________ Fi= rst Name: ____________________________= ______ MI:= _______

Drivers License #: _____________________________________________ Drivers License State: ______________________________

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

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

Last Name: = ____________________________= __________________ Fi= rst Name: ____________________________= _____ MI= : _______

Drivers License #: _____________________________________________ Drivers License State: ______________________________

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

□ = Senior Exemption excludes those over 65 or on Soc= ial 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 pertinent to y= our 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>

$ 56.25

Account Maintenance

$ 41.25

Refundable Deposit=

$ 75.00

Total Water

$ 172.50

After Hours Fee

TOTAL DUE:=

Check #: __________________

<= /i>

THIS DOCUMENT MUST BE VAL= IDATED

ON LINE FORM

AGREEMENTS: AMUD SERVICE – NON 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.

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 commissions 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 REPRESENTATIVES 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 expiration 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.

<= /b>

=

=

=

=

Primary Customer Signature

=

Joint Customer Signature

AMUD Representative

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

Last Name: = ____________________________= _________________ Fi= rst Name: ____________________________= ______ MI:= _______

Last Name: = ____________________________= _________________ Fi= rst Name: ____________________________= ______ MI:= _______

Today’s D= ate: _____ / _____ / _____

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 pertinent to y= our 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>	$ 56.25
Account Maintenance	$ 41.25
Refundable Deposit=	$ 75.00
Total Water	$ 172.50
After Hours Fee
TOTAL DUE:=

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