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Application for New Water Service

2. Purpose
   The City of Glenn Heights is responsible for protecting the drinking water supply from contamination or pollution, which could result from improper plumbing practices. The purpose of this service agreement is to notify each customer of the plumbing restrictions, which are in place to provide this protection.
   
   The utility enforces these restrictions to ensure the public health and welfare. Therefore each customer must sign this agreement before the City of Glenn heights will begin service. In addition, when service to an existing connection has been suspended or terminated the water system will not re-establish service unless it has a signed copy of this agreement.
4. Service Agreement
   The following is the terms of the service agreement between the City of Glenn Heights (the water system) and the customer:

   1. The water system will maintain a copy of this agreement as long as the customer and/or the premises are connected to the water system.
   2. The customer shall allow his property to be inspected for possible cross-connections and other undesirable plumbing practices. These inspections shall be conducted by the water system or its designated agent prior to initiating service and periodically thereafter. The inspections shall be conducted during the water system's normal business hours.
   3. The water system shall notify the customer in writing of any cross-connection or other undesirable plumbing practice, which has been identified during the initial inspection or the periodic re-inspection.
   4. The customer shall immediately correct any undesirable plumbing practice on his premises.
   5. The customer shall, at his expense, properly install, test, and maintain any backflow prevention device required by the water system. Copies of all testing and maintenance records shall be provided to the water system.
6. Enforcement
   If the customer fails to comply with the terms of the service agreement, the water system shall, at its option, either terminate service or properly install, test, and maintain an appropriate backflow prevention device at the service connection. Any expenses associated with the enforcement of this agreement shall be billed to the customer.
8. Customer Name*
10. Address
12. Did you read the requirements?*

    1. Yes
16. Name*
17. Spouse Name
19. Service Address*
21. Date of Birth*
    Date of Birth
22. Spouse Date of Birth
    Spouse Date of Birth
24. Date Service Needed*
    Date Service Needed
26. Place of Employment
28. Home Phone
29. Cell Phone
30. Work Phone
32. Have you ever been a Glenn Heights water customer?*

    1. Yes
    2. No
34. Bills not paid in full by the due date are charged a late fee of 15% or $25 whichever is greater of the total current charges. Accounts not paid in full within 20 days after the due date will be disconnected and assessed a reconnect fee of $35.
36. Applicant's Name*
38. Do you agree that all the above information is correct?*

    1. Yes
Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

* indicates a required field