Village of Tijeras | Pride in our past and faith in our future



495300200025Application for PublicWater Service00Application for PublicWater ServiceName:_________________________________________Physical Address:_________________________________________Mailing Address:_________________________________________Home Phone: ___________ Cell: ___________ Work: ___________Type of Service Requested (check one):9144004762500 Residential9144002984500 Commercial or BusinessDescription ____________________________________________________________________9144002222500 OtherDescription ____________________________________________________________________238125234950For Office Use Only: Water Account Number____________________ Date of On-Site Inspection____________________ Date Meter Installed____________________ Meter Size____________________Meter Serial Number____________________00For Office Use Only: Water Account Number____________________ Date of On-Site Inspection____________________ Date Meter Installed____________________ Meter Size____________________Meter Serial Number____________________9156701654175009156701339850009156701025525009156707112000091440039687500M.D.W.C.A. WATER RIGHTS SURVEYName and Address of MemberNumber of Persons In Family____________________________________________________________________________________________________________________________________________________Present source of water (surface or ground): GroundwaterOwner of present source from above: _________________________________If present source is a well, give date well was drilled. _________________________If well was drilled after the Declaration of Extension of the basin, give the State Engineer fileor permit number: _______Location of present source of water (refer to your property tax notice or warranty deed for location.________________________________________________________________________________________________________________Initial below your agreement to convey inside the house use water rights from member toAssociation: YES______NO__________________________________________________ _________ Signature DateSubscribed and sworn to before me this ________day of _________, A.D., 20_____.My commission expires: _______________________________________ Notary PublicWitness to Signature (in lieu of Notary Public)1. _______________________________________2. _______________________________________M.D.W.C.A. FILE OR PERMIT NUMBER: RG-51777 ................
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