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83 Move In Form

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CITYOFARANSASPASS.UTILITYSERVAPPREVISED10/15/09.DOC
RESIDENTAL MOVE IN FORM
CITY OF ARANSAS PASS
UTILITY SERVICE APPLICATION
ACCOUNT: DATE:
MOVE IN: _______ REACTIVE: ________
SERVICE NAME: MAILING NAME: ________
ADDRESS: MAILING ADDRESS: ________________________________________
SSN #: ____________________________________________ CITY: _____________________________________________________
TELEPHONE #: STATE/ZIP:
DRIVER LIC #: DEPOSIT DATE: _______ ON HOLD
EMPLOYER: DEPOSIT AMOUNT: ________________________________________
WORK # ___________________________________________ DEPOSIT #:________________________________________________
METER #: _________________________________________ DOES PROPERTY HAVE A WATER WELL? ______________________
RENT: __________ OWN: __________ WATER ________ SEWER _________ GARBAGE ______________
LANDLORD’S NAME: _________________________________
LANDLORD’S #: _____________________________________
The undersigned applicant hereby requests the City of Aransas Pass, Texas hereinafter called the City, to provide and install to the premises, described
above, service line of lines and all necessary fittings and equipment to provide water and/or sewer service to the property of the applicant, and in
consideration of the City’s investment in so doing, applicant has granted, and by these presents does grant, to the City, its successors and assigns, a right of
way and easement under, on, along, and over said premises in and upon which to install and maintain such above described service line or lines and
equipment. It is understood and agreed that such service line or lines and equipment shall be and remain the property of the City; that the City shall have the
right to enter on said premises at any time for all purposes connected with said services and repair and maintenance of said service line or lines and
equipment; and, if said service, or services shall be discontinued on said premises for any cause, City shall have and is hereby given the unqualified right to
enter thereon at any time, remove and repossess itself of said service line, or lines and all said equipment, all damages and costs in connection therewith
and with City’s exercise of any right here in and/or by the undersigned granted to City being hereby expressly waived. Undersigned applicant, his successors
and assigns, agree to protect City’s property on said premises and will not tamper with or remove such property or permit same to be done without the City’s
consent. For providing said service line or lines, the applicant agrees to pay, when due, the appropriate fees for water services and/ or sewer service and/or
garbage service. The applicant further requests and agrees to take and pay City for such service and/or services supplied to say premises at City’s rates at
any time prevailing and established and upon its terms at any time applicable to the class of service furnished.
TURN ON DATE: SERVICE ORDER #: ____________________________
REMARKS:
-------------------------------------------------------------------------------------OFFICE USE ONLY-------------------------------------------------------------------------------------------
BY WHOM: DATE:
*SIGNATURES ON BACK OF THIS PAGE**
CITYOFARANSASPASS.UTILITYSERVAPPREVISED10/15/09.DOC
CITY OF ARANSAS PASS
UTILITY SERVICE APPLICATION
1. PURPOSE. The Aransas Pass Water Department is responsible for protecting the drinking
water supply from contamination of pollution, which could result from improper plumbing practices. The
purpose of this service agreement is to notify each customer of the plumbing restrictions, which are in place to
provide this protection. The Water Department enforces these restrictions to ensure the public health and
welfare. Each customer must sign this agreement before the Aransas Pass Water Department will begin service.
In addition, when service to an existing connection has been suspended or terminated, the water system will not
re-establish service unless it has a signed copy of this agreement.
2. PLUMBING RESTRICTIONS. The following undesirable plumbing is prohibited by state
regulations.
A. No direct connection between the public drinking water supply and a potential source of
contamination is permitted. Potential sources of contamination shall be isolated from the public
water system by an air gap or an appropriate backflow prevention device.
B. No cross-connection between the public drinking water supply and a private water system is
permitted. These potential threats to the public drinking water supply shall be eliminated at the
service connection by the installation of an air-gap or a reduced pressure-zone backflow prevention
device.
C. No connection, which allows water to be returned to the public drinking water supply, is permitted.
D. No pipe or pipe fitting which contains more that 8.0% lead may be used for the installation or repair
of plumbing at any connection, which provides water for human use.
E. No solder or flux, which contains more than 0.2% lead, can be used for the installation or repair of
plumbing at any connection, which provides water for human use.
3. SERVICE AGREEMENT. The following are the terms of the service agreement between the Aransas
Pass Water Department (the Water System) and the customer signed below.
A. The Water System will maintain a copy of this agreement as long as the customer and/or the premises
are connected to the Water System.
B. The Customer shall allow his property to be inspected for the possible cross-connections and other
undesirable plumbing practices. These inspections shall be conducted by the Water System or its
designated agent prior to initiating service and periodically thereafter. The inspections shall be
conducted during the Water System’s normal business hours.
C. The Water System shall notify the customer in writing of any cross-connection or other undesirable
plumbing practice, which has been identified during the initial inspection or the periodic reinsertion.
D. The Customer shall immediately correct any undesirable plumbing practice on his premises.
E. The Customer shall, at his expense, properly install, test, and maintain any backflow prevention
device required by the Water System. Copies of all testing and maintenance records shall be provided
to Water System.
4. ENFORCEMENT. If the customer fails to comply with the terms of the service agreement, the Water
System shall, at its option, terminate service or properly install, test, and maintain an appropriate backflow
prevention device at the service connection. Any expense associated with the enforcement of the agreement shall
be billed to the customer.
CUSTOMER SIGNATURE ____ DATE
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83 Move In Form

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Completed 16 July 2020

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