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If you would like to connect, disconnect or transfer water service, please fill out this form in its entirety. You will have to repeat the process for each service.
Once your application has been reviewed and approved, a representative will contact you for a security deposit.
SERVICE ADDRESS
*
MAILING ADDRESS (if different)
REQUEST TYPE
*
New Service
Disconnect Service
Transfer Service
IF TRANSFERRING SERVICE: NEW ADDRESS AND DATE TO TURN OFF OLD ADDRESS AND DATE TO TURN ON NEW ADDRESS
5000 characters remain
OWN OR RENT
*
IF RENTING, LANDLORDS NAME AND PHONE (COPY OF LEASE REQUIRED)
PRIMARY ACCOUNT HOLDER
OCCUPANT?
*
YES
NO
LAST NAME
*
FIRST NAME
*
DATE OF BIRTH
*
SSN
*
CELL PHONE NUMBER
*
HOME PHONE NUMBER
EMAIL ADDRESS
*
EMPLOYER'S NAME AND PHONE
*
SECONDARY ACCOUNT HOLDER (IF APPLICABLE)
OCCUPANT?
YES
NO
LAST NAME
FIRST NAME
DATE OF BIRTH
SSN
CELL PHONE NUMBER
HOME PHONE NUMBER
EMAIL
EMPLOYER NAME AND PHONE
WOULD YOU LIKE TO BE ENROLLED IN THE OPTIONAL RECYCLING PROGRAM FOR $6 MORE PER MONTH?
*
YES
NO
DATE SERVICE TO BEGIN (NEW SERVICE) if applicable
DATE SERVICE TO END (DISCONNECT) if applicapable
I acknowledge that the above information is true and correct and I hereby apply for water, sewer, & trash service. Furthermore, I agree to comply with all ordinances, rules or regulations as prescribed by the City of Pleasant Hill applicable to the furnishing of water, sewer, & trash service, including never tampering and / or destruction of the water meter itself.
SIGNATURE AND DATE
*
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