Utility Service Application

Water / Sewer / Trash Service *

Additional Trash Cart ($1.35)

Yes

Service Address *

Mailing Address (If Different)

City

State

Zip

Primary Account Holder

Occupant *

Last Name *

First Name *

Date of Birth *

SSN *

Phone Number *

Employer Name *

Employer Phone *

Email Address *

Paperless Billing *

Secondary Account Holder (If Applicable)

Occupant

Last Name

First Name

Date of Birth

SSN

Phone Number

Employer Name

Employer Phone

Email Address

Own or Rent *

Landlord Name (copy of lease required)

Landlord Phone Number

Request Type *

Service Start Date

Service End Date

Forwarding Address

City

State

Zip

Attachments

Lease agreement (if renting)

Please upload a copy of your lease if you are renting.

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 tampering and / or destruction of the water meter itself.

Signature*

Signature Date

04/23/2025

Utility Service Application

Primary Account Holder

Secondary Account Holder (If Applicable)

Attachments

My Account