Customer App PG 1

Montgomery County WCID #1

APPLICATION FOR RESIDENTIAL UTILITY SERVICE

Account #

Name of Customer(Required)

Date of Birth

Account Activation Date

Volunteer Fire Dept.*: $2 (Monthly)

Yes

Driver License/ID & State*:

Primary Phone(Required)

Secondary:

Email(Required)

Enter Email Confirm Email

Service Address(Required)

Street City State / Province / Region ZIP / Postal Code

Billing address (if different)

Street City State / Province / Region ZIP / Postal Code

Please Check One:

I own this property (proof of ownership required) $200 (refundable deposit) +$25 Set up fee

I rent this property (proof of lease required) $200 (refundable deposit) +$25 Set up fee

I manage this property (listing agreement required) $200 (refundable deposit) +$25 Set up fee

Owner’s Account number

The deposit and connection fee must be paid by cash, check, money order, or credit card (a 2.5% processing fee will be applied) before service is rendered.

By signing you agree to the terms herein, the Customer Service Agreement, do grant permission for District’s Operator to turn on water service at the Service Address without anyone present and understand the District will not be held responsible for consequent damage to property, and understand you are bound to the cost for all services set by and listed in the District’s Rate Order. Applicant’s Failure to adhere to all requirements contained in the District’s Rate Order may result in fines, penalties and delay or denial of service initiation. A copy of the District’s Rate Order is available upon request and on the Montgomery County WCID #1’s website, here: wcid1tx.org

Printed Name:

Date

Signature

Service Agreement

I. PURPOSE. Montgomery County WCID #1 is responsible for protecting the drinking water supply from contamination or pollution which could result from improper system construction or configuration on the retail connection owner's side of the meter. The purpose of this service agreement is to notify each customer of the restrictions which are in place to provide this protection. The public water system enforces these restrictions to ensure the public health and welfare. Each retail customer must sign this agreement before Montgomery County WCID #1 begins service. In addition, when service to an existing retail connection has been suspended or terminated, the water system will not re-establish service unless it has a signed copy of this agreement.

II. RESTRICTIONS. The following unacceptable practices are prohibited by State regulations.

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 airgap or an appropriate backflow prevention device.
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 installation of an airgap or a reduced pressure-zone backflow prevention device.
No connection which allows water to be returned to the public drinking water supply is permitted.
No pipe or pipe fitting which contains more than 0.25% lead may be used for the installation or repair of plumbing at any connection which provides water for human use.
No solder or flux which contains more than 0.2% lead can be used for the installation or repair of plumbing at any connection which provides water for human use.

III. SERVICE AGREEMENT: The following are the terms of the service agreement between Montgomery County WCID #1 and (the Customer)

IV. The Customer shall, at his expense, properly install, test, and maintain any backflow prevention device required by Montgomery County WCID #1. Copies of all testing and maintenance records shall be provided as well.

V. ENFORCEMENT. If the Customer fails to comply with the terms of the Service Agreement, Montgomery County WCID #1 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.

VI. OWNERS/MANAGEMENT COMPANIES. This agreement must remain in the current tenant’s name until the tenant moves out, at which time the agreement reverts to the owner or management company. If the owner or management company wants the water off, notification must be sent to Montgomery County WCID #1 in writing.

Signature

Date

Name of Customer*:

Date of Birth*:

Account Activation Date*:

Volunteer Fire Dept.*: $2

Yes No

Driver License/ID & State*:

Primary Phone*:

Secondary:

Email Address*:

Agree Or Not

I agree to provide my above information and understand the District may contact me via phone, text and/or email for emergencies and other pertinent matters. Check here if you wish to opt-out

Service Address*:

City*:

State*:

Zip*:

Billing address (if different)*:

City*:

State*:

Zip*:

Please Check One:

I own this property (proof of ownership required) $200 (refundable deposit) +$25 Set up fee I rent this property (proof of lease required) $200 (refundable deposit) +$25 Set up fee I manage this property (listing agreement required) $200 (refundable deposit) +$25 Set up fee

Owner’s Account number

The deposit and connection fee must be paid by cash, check, money order, or credit card (a 2.5% processing fee will be applied) before service is rendered.

By signing you agree to the terms herein, the Customer Service Agreement, do grant permission for District’s Operator to turn on water service at the Service Address without anyone present and understand the District will not be held responsible for consequent damage to property, and understand you are bound to the cost for all services set by and listed in the District’s Rate Order. Applicant’s Failure to adhere to all requirements contained in the District’s Rate Order may result in fines, penalties and delay or denial of service initiation. A copy of the District’s Rate Order is available upon request and on the Montgomery County WCID #1’s website, here: wcid1tx.org

Printed Name:

Date

Signature

Service Agreement

II. RESTRICTIONS. The following unacceptable practices are prohibited by State regulations.

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 airgap or an appropriate backflow prevention device.
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 installation of an airgap or a reduced pressure-zone backflow prevention device.
No connection which allows water to be returned to the public drinking water supply is permitted.
No pipe or pipe fitting which contains more than 0.25% lead may be used for the installation or repair of plumbing at any connection which provides water for human use.
No solder or flux which contains more than 0.2% lead can be used for the installation or repair of plumbing at any connection which provides water for human use.

III. SERVICE AGREEMENT: The following are the terms of the service agreement between Montgomery County WCID #1 and (the Customer)

Signature

Date