|
Account #: ________________________ Premise #:
________________________ Cycle: _____ Route: ______ Seq: ______ |
|
=
Today’s
Date: ____ / ____
/ ____ Work Order #:
_________________ =
Start
Service By: ____
/ ____ / ____ PERMIT #: __________________ |
![3D"[AMUD](3D"TapConnection_files/image002.jpg")
WATER/SEWER
CONNECTION PURCHASE
Service Address: <=
/span>_____________________________=
_____________________________________________
&=
nbsp; &nbs=
p; &=
nbsp; Phase/Block
#: _________________
Mailing Address: <=
/span>____________________________=
_____________________________________________________________________
PRIMARY ON ACCOUNT
Last Name: =
____________________________=
_________________ Fi=
rst
Name: ____________________________=
______ MI=
: _______
Drivers License #:
_____________________________________________
Date of Birth: _____ / _____
/ _____
Home Phone: ( _______ ) ________
- _________ Work Phone:&nbs=
p;
( _______ ) ________
- ________
JOINT ACCOUNT
INFORMATION
(By desi=
gnating
a Joint Customer you are allowing that person access to your account
information.)
Last Name: =
____________________________=
__________________ Fi=
rst
Name: ____________________________=
_____ MI:=
_______
Drivers License #:
_____________________________________________
Date of Birth: _____ / _____
/ _____ &nbs=
p;
Home Phone: ( _______ ) ________
- _________ Work Phone:&nbs=
p;
( _______ ) ________
- ________
|
Yes |
No |
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|
<=
span
style=3D'font-size:8.0pt'>Do you have an irrigation system? |
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|
|
<=
span
style=3D'font-size:8.0pt'>Do you irrigate from lake, river or other water
source? |
|
<=
span
style=3D'font-size:8.0pt'> &nbs=
p;
Specify: ___________=
__________________ |
||
|
|
|
<=
span
style=3D'font-size:8.0pt'>Do you have a well? |
|
|
|
<=
span
style=3D'font-size:8.0pt'>Do you have a septic system? |
|
|
|
<=
span
style=3D'font-size:8.0pt'>Do you have a Grinder Pump Low pressure sewer s=
ystem? |
|
|
|
<=
span
style=3D'font-size:8.0pt'>Do you have a customer cutoff valve at tap? |
|
|
|
<=
span
style=3D'font-size:8.0pt'>Do you have hose bib vacuum breakers on outside
faucets? |
Plumber - NAME AND LICENSE NUMBER
Electrician - NAME AND LICENSE NUMBER
Contractor
ON LINE FORM
|
WATER CONNECTION |
FEES |
Meter Upgr=
ade |
||
|
|
|
Meter Set Fee |
$ 1=
65.00 |
|
|
|
|
Account Maintenance |
$ &nb=
sp;
15.00 |
|
|
|
|
Refundable Deposit |
$ &nb=
sp;
75.00 |
|
|
|
|
Impact Fee std 5/8=
221;
mtr |
$ 3,000.00 |
|
|
|
|
Mtr Upgrade Impact Fee |
|
|
|
|
|
Water Tap Fee |
$ 4=
80.00 |
|
|
|
|
Additional Water Tap Fee |
|
|
|
|
|
Plumbing Inspection F=
ee |
$ &nb=
sp;
90.00 |
|
|
|
|
TOTAL CONNECT FEE |
$ 3,825.00 |
|
|
SEWER CONNECTION |
FEES |
DCBE / PEC=
AN |
||
|
|
|
Impact Fee std 5/8 mt=
r |
$ 2,738.00 |
|
|
|
|
Mtr Upgrade Impact Fee |
|
|
|
|
|
Sewer Tap Fee |
$ 3=
75.00 |
|
|
|
|
Plumbing Inspection F=
ee |
$ &nb=
sp;
30.00 |
|
|
|
|
TOTAL CONNECT FEE |
$ 3,143.00 |
|
|
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|
After Hours Fee |
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|
TOTAL DUE:<= o:p> |
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CHECK #: |
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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.
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
11.
AMUD WILL NOT ESTABLISH SERVICE TO PREMISE IF PL=
UMBING
INSPECTIONS ARE NOT COMPLETED.
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=
|
=
|
=
|
|
=
|
|
Primary Customer Signature |
=
|
Joint Customer Signature |
|
AMUD Representative |
Service Address: <=
/span>____________________________=
______________________________________________
Last Name: =
____________________________=
_________________ Fi=
rst
Name: ____________________________=
______ MI:=
_______
Last Name: =
____________________________=
_________________ Fi=
rst
Name: ____________________________=
______ MI:=
_______
Today’s
Date: _____
/ _____ / _____