000 X. Xxxxxx Xxxxxx PO Box 297
Xxxxxx, XX 00000 Fax 000-000-0000
XXXXXX WATER DEPARTMENT SERVICE APPLICATION AND AGREEMENT
AGREEMENT made this day of , 20 , between
the TOWN OF XXXXXX, (Hereinafter called the Town) and
Applicant Full Name – Please Print
(hereinafter called the Applicant).
Applicant’s Social Security Number Applicant’s Date of Birth
Driver’s License (Number, State) **Copy must be provided for services to begin**
Service Address (Number, Street, City, State, Zip)
Xxxxxxx Xxxxxxx (Xxxxxx, Xxxxxx, Xxxx, Xxxxx, Zip)
( ) ( ) Home Phone Cell Phone Email Address
Work Name Phone
DATE TO TURN ON SERVICE
IF RENTAL PROPERTY PLEASE FILL OUT THE FOLLOWING:
Mailing Address: City, State, Zip: Phone: ( ) Fax: ( )
FOR OFFICE USE ONLY
Approved and Accepted by:
Check Check #
Credit Card Authorization#
Visa MC Other:
The Town shall sell and deliver water and/or wastewater service to the Applicant and the Applicant shall purchase, receive, and/or reserve service from the Town in accordance with the Ordinances adopted by the Town.
The Applicant shall pay the Town for service hereunder as determined by the Town’s Ordinances. A copy of this agreement shall be executed before service may be provided to the Applicant.
The City Council shall have the authority to discontinue service of Applicant not complying with any policy or not paying any utility fees or charges as required by the Town’s Ordinances, fees, and conditions of service. If, at any time, service is discontinued, terminated or suspended, the Town shall not reestablish service unless it has a current, signed copy of this agreement.
All water shall be metered by meters to be furnished and installed by the Town. The meter and/or wastewater connection is for the sole use of the Applicant and is to provide service to only one (1) dwelling or one (1) business. Extension of pipe(s) to transfer utility service from one property to another, to share, resell, or sub meter water to any other persons, dwellings, businesses, or property, etc., is prohibited.
The Town shall have the right to locate a water service meter and the pipe necessary to connect the meter on the Applicant’s property at a point to be chosen by the Town and shall have access to its property and equipment located upon Applicant’s premises at all reasonable and necessary times for any purpose connected with or in the further operation of its business operations, and upon discontinuance of service.
During construction grading, landscaping, etc. if the meter box is damaged or broken, there will be a charge of $100.00 for replacement of the meter box unless it is a Badger Radio Read meter, then the price is
$250.00 and up. All locations connected to the Town of Ponders Water System will have a cut-off between the meter box and the building, barn, etc.
The Town is responsible for protecting the drinking water supply from contamination or pollution which could result from improper plumbing practices. This service agreement serves as notice to each Applicant of the plumbing restrictions which are in place to provide this protection. The Town shall enforce these restrictions to ensure the public health and welfare. The following undesirable plumbing practices are prohibited by state regulations:
A. No direct connection between the public drinking water supply and a potential source of contamination is permitted. Potential sources of contamination shall be isolated from the public water system by an air gap or an appropriate backflow prevention assembly in accordance with state plumbing regulations. Additionally, all pressure relief valves, and thermal expansion devices must be in compliance with state plumbing codes.
B. No cross-connection between the public drinking water supply and a private water system is permitted. These potential threats to the public drinking water supply shall be eliminated at the service connection by the proper installation of an air gap or a reduced pressure-zone backflow prevention assembly and a service agreement must exist for annual inspection and testing by a certified backflow prevention device tester.
C. No connection which allows condensing, cooling, or industrial process water to be returned to the public drinking water supply is permitted.
D. No pipe or pipe fitting which contains more than 8.0% lead may be used for the installation or repair of plumbing on or after July 1, 1988, at any connection which provides water for human consumption.
E. No solder or flux which contains more than 0.2% lead may be used for the installation or repair of plumbing on or after July 1, 1988, at any connection which provides water for human consumption.
The Town shall maintain a copy of this agreement as long as the Applicant is connected to the public water system. The Applicant shall allow his property to be inspected for possible cross connections and other undesirable plumbing practices. These inspections shall be conducted by the Town or its designated agent prior to initiating service and periodically thereafter. The inspections shall be conducted during the Town’s normal business hours. The Town shall notify the Applicant in writing of any cross-connections or other undesirable plumbing practices which have been identified during the initial or sub sequent inspection. The Applicant shall immediately correct any undesirable plumbing practice on their premise.
The Applicant shall, at his expense, properly install, test, and maintain any backflow prevention device required by the Town. Copies of testing and maintenance records shall be provided to the Town as required. Failure to comply with the terms of this service agreement shall cause the Town to 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 Applicant.
If a sprinkler system is installed, it must be under a separate permit and a completed “Backflow Prevention Assembly Test Report” must be submitted to the permitting office. An inspection must be done every year and submitted to the permitting office. If the sprinkler system is constructed in the Town’s utility easement and the Town needs to make repairs to the water/sewer lines, the Town of Xxxxxx is not responsible for any damage done to the sprinkler system.
By execution hereof, the Applicant shall hold the Town harmless from any and all claims for damages caused by service interruptions due to waterline breaks by utility or like contractors, tampering by other Applicants of the Town, normal failures of the system or other events beyond the Town’s control.
The Applicant shall grant to the Town, now or in the future, any easements of right-of-way for the purpose of installing, maintaining, and operating such pipelines, meters, valves, and any other equipment which may be deemed necessary by the Town to extend or improve service for existing or future Applicants, on such fare as are required by the Town.
By execution hereof, the Applicant shall guarantee payment of all other rates, fees, and charges due the Town. Liquidation of said Applicant fees shall give rise to discontinuance of service under the terms and conditions of the Town’s Ordinance.
By execution hereof, the Applicant agrees that noncompliance with the terms of this agreement by said Applicant shall constitute denial or discontinuance of service until such time as the violation is corrected to the satisfaction of the Town.
Any misrepresentation of the facts by the Applicant on this agreement shall result in discontinuance of service pursuant to the terms and conditions of the Town’s Ordinances.
N O T I C E
Request for Confidentiality of Personal Information Maintained by the Town of Xxxxxx Utilities Department.
Personal information in your Town of Xxxxxx Utilities Department Applicant account records (e.g., name, address, telephone number, or social security number) is generally considered public information under the Texas Government Code, Chapter 552 (Public Information Act).
The Texas Utilities Code, Chapter 182 (Rights of Utilities Customers), provides that a government- operated utility may not disclose personal information if the Applicant requests that the government-operated utility keep the personal information confidential.
This form enables you to request confidentiality of your personal information under Texas Utilities Code, Chapter 182.
If you wish to request confidentiality of your personal information, please check the box below.
I request that my personal information maintained by the Town of Xxxxxx Utilities Department be kept confidential under Texas Utilities Code, Chapter 182. I understand that the Town of Xxxxxx Utilities Department may charge each Applicant who requests confidentiality under this subchapter a fee not to exceed the administrative cost of complying with the request of confidentiality. The fee charged by the Town of Xxxxxx Utilities Department for this Service is $ 0.00. (No Charge)
* A request for confidentiality under Chapter 182 does not prohibit a government operated utility from disclosing personal information in a Applicant’s account record to: (1) an official or employee of the state, a political subdivision of the state, or the United States acting in an official capacity; (2) an employee of a utility acting in connection with the employee’s duties; (3) a consumer reporting agency; (4) a contractor or subcontractor approved by and providing services to the utility, the state, a political subdivision of the state, or the United States; (5) a person for whom the Applicant has contractually waived confidentiality for personal information; or (6) another entity that provides water, wastewater, sewer, gas garbage, electricity, or drainage service for compensation. An Applicant may rescind a request for confidentiality by providing the government-operated utility written permission to disclose personal information. A government-operated utility or an officer or employee of a government-operated utility is immune from civil liability for a violation of Texas Utilities Code, Subchapter B.
I have received a copy of the “TOWN OF XXXXXX WATER DEPARTMENT SERVICE AGREEMENT”. I have read this notice and understand the conditions stated.
1. The Town of Xxxxxx sends a xxxx for the minimum amount due each month. It is the Applicant’s responsibility to make sure payments are made on time regardless of the delivery method.
2. All payments must be received at Town Hall by the close of business on the due date. The due date is on the 15th day of the month unless the 15th falls on a Friday or Town of Xxxxxx non-workday, payments will be due on the next business day. If you are unsure of the exact due date, please call Town Hall.
3. Any payment placed in the drop box after Town Hall business hours will be posted to your account the NEXT BUSINESS DAY. A $20.00 late fee will be charged for payments made after Town Hall business hours on the due date.
TOWN HALL BUSINESS HOURS:
Monday – Thursday 7:30 AM to 5:00 PM Friday 7:30 AM to 11:30 AM
4. Accounts with unpaid balances remaining 10 days after the due date will be subject to disconnect. There is a reconnect fee of $40.00 and the reconnect can only be done during regular Town Hall business hours.
I have received a copy of the WATER AND SEWER LATE FEES & COLLECTION POLICY FOR THE TOWN OF XXXXXX. I have read this page and understand the conditions stated.
PAYMENT OPTIONS AVAILABLE
CASH – CHECK – DEBIT Card – CREDIT Card (Visa, Mastercard, Discover)
You can come into Town Hall and make a payment with cash, check (no post-dated checks will be accepted nor will checks be held in the office) or credit/debit card (there is a fee for all credit/debit transactions), call and make a credit/debit card payment over the phone or drop your CHECK payment in the drop box located by the front door of Town Hall. DO NOT put CASH in the drop box. Any payments put in the drop box after Town Hall business hours will be posted to your account the NEXT BUSINESS DAY.
TOWN HALL BUSINESS HOURS:
Monday – Thursday 7:30 AM to 5:00 PM Friday 7:30 AM to 11:30 AM
ON-LINE XXXX PAY
Visit our Town Website, xxx.xxxxxxxx.xxx, and use the ONLINE PAYMENTS link from the home page. This will take you to FastGovPay and follow the steps to quickly pay your xxxx. You will need your account number. If you do not have that information contact Town Hall at (000)000-0000 or (000)000-0000. You may also set up an account in FastGovPay which will allow you the option to sign up for auto pay and allow you to see your account transactions.
AUTO BANK DRAFT
The Application and Policy are available at Town Hall. You can also make a request for the Application and Policy by sending an email to firstname.lastname@example.org or email@example.com. Once the application has been completed and approved, your water/sewer xxxx will be automatically withdrawn from the checking/saving account you designate. Any changes or cancellations to the Auto Bank Draft will have to be made in writing. Please refer to the Auto Bank Draft Policy.
SENIOR CITIZEN BILLING PROGRAM
If you are over sixty (60) years old AND you are the Applicant for water/sewer services, the Town of Xxxxxx will give you until the 26th of each month to pay your xxxx without any late fees. You MUST request to be on the Senior Citizen Billing Program.