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Existing Structures
Billing Agreement
New Constuction
New Service Application
"
*
" indicates required fields
Step
1
of
3
33%
Please Choose a Form
*
Please Choose a Form
Billing Agreement - Structure Has Had Prior Water Service
New Service Application - New Water Hook-Up Needed
Billing Agreement
FOR
TURN WATER ON
FOR A STRUCTURE WHICH HAS PREVIOUSLY HAD WATER SERVICE.
>>>PLEASE READ<<< If you are requesting service for BRAND NEW WATER HOOK-UP which has never had water service in the past, please change your selection to "New Service Application - New Water Hook-Up Needed".
New Service Application
FOR
NEW WATER HOOK-UP
THAT HAS NEVER HAD WATER SERVICE.
>>>PLEASE READ<<< If you are requesting service for a STRUCTURE WHICH HAS HAD WATER SERVICE in the past, please change your selection to "Billing Agreement - Structure Has Had Prior Water Service"
Application Date
*
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Account Number
Property (Service) Location
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Map
Map
Lot
Lot
Water Usage
Please specify the percentage this property is used for personal, business, or government purposes.
This is for Maine State Bureau of Taxation. All water used for business purposes is taxable. If not completed, commercial property will be taxed at 100%. Must be broken down to nearest 10%.
Type of Service
*
Residential
Commercial
Government
Percentage used for Personal
*
Percentage used for Business
*
Percentage used for Government
*
Annual or Seasonal?
*
ANNUAL: Year round water service at the same premises. (Quarterly Billing)
SEASONAL*: Includes intermittent use, season after season, at the same premises. (Seasonal Billing)
*Where available
Previous Owner of this Location
*
Applicant Name
*
First
Last
Applicant Phone Number
*
Applicant Name
First
Last
Applicant Phone Number
Co-Applicant Name (if applicable)
First
Last
Co-Applicant Phone Number
Business or Government Name
Business/Gov't Phone Number
Business or Government Name
*
Business/Gov't Phone Number
*
Applicant Email
*
Applicant Date of Birth
*
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Applicant Date of Birth
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Applicant Mailing Address
*
Same as Property (Service) Location
Street Address
Suite / Apt. / P.O. Box
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Credit History
Do you owe any outstanding bills for water?
*
Yes
No
Have you filed bankruptcy within the past 6 years?
*
Yes
No
Employer's Phone Number
*
Applicant Place of Employment / Income Source
*
Driver's License Number
*
SS Number
*
Fed. Tax ID / EIN
SS Number
Fed. Tax ID / EIN
*
Release
*
I agree
I/We hereby give the Boothbay Region Water District permission to release any and all information which may be deemed necessary in order for collection of any outstanding debts I/we may occur to the Water District.
Residential
Residential Type
*
Single Family
Rental
Apartment
Condo
Duplex
Will there be
*
Fire Protection
Pool
Underground Irrigation (Requires Separate Line)
None of the Above
Will there be a Pressure Tank / Booster Pump installed on public water supply?
*
Yes
No
Commercial
Commercial Type Water Use
*
Restaurant
Primary Food Processing
Harvested Sea Products
Professional (medical)
Professional (non-medical)
Retail (perishable)
Retail (non-perishable)
Day Care
Nursing Home
Entertainment
Inn, Hotel, or Motel
Irrigation
Agriculture
Aquaculture
Light Manufacturing
Heavy Manufacturing
Peak Flow Season
*
Peak Demand
*
Peak Daily Flow
*
Peak Pressure Need
*
Ave. Demand
*
Ave. Daily Flow
*
Ave. Pressure Need
*
Government
Government Type
*
Local
State
Federal
Quasi-Municipal
Government Type Water Use
*
Additional Info/Comments
Common Questions
Please Provide Number of Fixtures
Kitchen
*
Dishwasher
*
Washer
*
Laundry Tub
*
Outside Spigot
*
Lavatory
*
Bathtub/Shower
*
Toilet w/Flush Tank
*
Toilet w/Flush Valve
*
Others: Please List
Fire Protection/Sprinkler Required?
*
Yes
No
Sprinkler Line Size
*
Boothbay Region Water District Responsibilities
1. Supply of potable water. 2. Installation of meter and meter findings.
Applicant Responsibilities
1. Cost of the service line from the water main to the building, plumbing, including excavation, and any permits required (ie., Road Opening) 2. If required, cost of tapping of water main to be reimbursed to the District. 3. Read and comply with the Boothbay Region Water District's Terms and Conditions of Service.
AGREEMENT TO PAY / TERMS AND CONDITIONS
Consent
*
I agree
*
I hereby contract with Boothbay Region Water District for water service and agree to pay for the same in accordance with the established rates of said Water District until written notice is given to discontinue said water service, and to conform to all Rules and Regulations of said Water District, now in force or which may hereafter be adopted, governing the use of water.
Consent
*
I agree
*
I understand that should my property ever be rented, and the tenant has water service in their name(s) and fails to make full payment I, as the property owner, am responsible for payment and agree to indemnify and hold harmless the Boothbay Region Water District from any and all debts and costs of collection in connection with said debt.
Consent
*
I agree
*
I have read and understand the above. I have also reviewed the BRWD Terms and Conditions of Service found on the
bbrwd2.wpengine.com/policies
webpage. I authorize the Boothbay Region Water District to enter the premises and access the property to inspect the service installation, normal maintenance of the water meter, evaluate, require and test backflow prevention devices, and evaluate potential usage. I further understand the estimated cost is to be paid in advance and any adjustments will be made upon completion of the work.
Equal Opportunity Program
Civil Rights Information Collection for USDA Financed Organizations
The following information is requested by the Federal Government in order to monitor compliance with Federal laws prohibiting discrimination against applicants seeking to participate in the program. You are not required to furnish this information but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race/nationality origin of individual applicants on the basis of visual observation or surname. Recipients using application forms will provide services and benefits in the order applications are received. A current waiting list will be maintained by the date and time an application is received, name of the applicant, race/national origin and a summary of the action taken. Above records will also reflect the number of applicants approved or rejected for the benefit or service by race/national origin. The recipient shall make a report of this information available to Rural Development employees, USDA officials, and other appropriate Federal employees, i.e., HUD or DOJ employees, as requested by telephone or written notice through an appropriate Rural Development Official.
Race
*
White
Black
Hispanic
American Indian or Alaskan Native
Asian or Pacific Islander
I prefer not to answer
Sex
*
Male
Female
I prefer not to answer
Applicant Signature
*
Applicant Signature Date
*
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Co-Applicant Signature
*
Co-Applicant Signature Date
*
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Name
This field is for validation purposes and should be left unchanged.