BUCKINGHAM PARK WATER DISTRICT



Location No.: ____________________

Name(s) of Account: Date:

Service Address: Account #:

A/P #: - - Meter No: Effective Date of Ownership Change: ____________________

A backflow prevention devise is , or is not required for this property. DL No.: _____________________

SECTION TO BE COMPLETED BY CUSTOMER(S)/APPLICANT(S)

Property Owner Billing Address:

Type of Service: Domestic , or Commercial . For email billing, please

provide an email address: . It is intended that

Primary Phone No. :( ) this property will be Owner Occupied , or Tenant Occupied , (please

Secondary Phone No. :( ) Specify if tenant is to receive a copy of bill, if tenant occupied).

SECTION FOR FEES PAID FOR EXISTING AND/OR NEW CONNECTIONS TO DISTRICT SERVICES

Capacity Expansion/Connection Fee Paid $ ______________________ (Fee represents proportionate cost of capacity in existing and future facilities)

Meter Installation & Maintenance Fee Paid $ ______________________ (Fee represents cost of meter for life of account)

Reconnect/Transfer Fee Paid $ ______________________ (Fee represents administrative servicing of account)

Misc/Other Fee Paid $ ______________________ (Fee represents administrative servicing of account)

Total Paid $ ______________________ Date Paid: _________________

*All amounts charged are as ordained by the District’s Board of Directors and are in accordance with the District’s current Rates & Fees Schedule.

ACKNOWLEDGMENT/AGREEMENT TO BE COMPLETED BY CUSTOMER(S)/APPLICANT(S)

The undersigned hereby applies to the Lower Lake County Waterworks District No. 1 for water service and/or a water service connection to be supplied to the address noted above, and promises to pay the Lower Lake County Waterworks District No. 1 in accordance with the schedule of water service rates and fees as ordained by the District’s Board of Directors, and to conform to and abide by District rules and regulations in force relating to the purchase and sale of said water service. The undersigned acknowledges the District’s right to access the customer’s premises to read the meter, make periodic inspections related to said water service, and to service District equipment, in accordance with District ordinance(s). Delivery of service shall be to the property line. The undersigned understands and acknowledges that for purposes of inspection, maintenance, construction, and to provide water service the District may or may not have the right to access utility easements recorded against the real property noted above. The undersigned agrees not to construct any permanent structure within any such easement which the District has easement rights to. The undersigned further acknowledges that by requesting connection to District water services, the District must maintain continual and sufficient treatment, distribution and storage capacity for this property eternally and that once connected to the District’s water system(s), said property must forever remain connected to the District’s water service system. Upon receipt of a Capacity Expansion Fee for a new connection, the District shall within 60 days of receipt of said fee, install a water meter at the property noted above, thereby furnishing water service to said property. Capacity Expansion/Connection Fees shall remain with the property for which the fee was originally intended, unless a Connection Fee Transfer has been approved by the District’s Board of Director’s, which shall be solely at the discretion thereof. Water meter installation time extension(s) may be granted on a case by case basis, which shall be at the discretion of the District’s Board of Director’s. All District fees, which may, or may not have been collected by the District at the time of this application, are considered to be non-refundable.

Applicant’s

Legal Name: Signature: Date:

Co-Applicant’s

Legal Name: Signature: Date:

Note: Schedules of District Rates and Fees, as well as the District’s Rules and Regulations referred to above will be furnished upon request, there may be incidental photocopying fees associated with reproduction of Fee Schedules and District Ordinances. A copy of your deed and proof of identification must be submitted with this application.

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