Fillable APPLICATION FOR WATER AND SEWER SERVICE (City of Rollingwood)

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APPLICATION FOR WATER AND SEWER SERVICE (City of Rollingwood)

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The APPLICATION FOR WATER AND SEWER SERVICE (City of Rollingwood) form is 5 pages long and contains:

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  • 13 check-boxes
  • 54 other fields

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File type: PDF

U.S.A. forms for City of Rollingwood

BROWSE CITY OF ROLLINGWOOD (TX) FORMS

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Office Use Only
Deposit Amount $500.00 Cash ______ Check Number ______ Work Order Number____________
Received By: ______________________
APPLICATION FOR WATER AND SEWER SERVICE
CUSTOMER INFORMATION
Customer Name (Please print)_______________________________________________________________
Service Address (Please Print)____________________________________________________
Are you: Owner Tenant
If Tenant, who is owner or agent?__________________ Owner Phone (____) ______________
____________________________________________________________________________
Mailing Address City State Zip Code
___________________________________________________________________________
Billing Address City State Zip Code
____________________________________________________________________________
Previous Address City State Zip Code
(____)_______________
Home Telephone Number
(____)_______________
Work Telephone Number
(____)________________
Cell Phone Number
_____________________________________________
E-mail Address (Please Print)
The undersigned hereby makes application to the City of Rollingwood for water and wastewater. I agree
to comply with the City’s Ordinances, Rules and Regulations as amended from time to time and to pay for
all utility services rendered to the property in a timely manner and understand that a violation of the
Ordinances, Rules or Regulations may result in a penalty and/or termination of utility services to above
service address. I represent that the information above is true and correct.
____________________________________ _______________________ __________________
Applicant Signature Application Date Effective Date
House Bill 859 requires “Government-Operated” Utilities to notify customers of their right to confidentiality.
You have the right to request confidentiality of your personal information contained in our records.
“Personal information” as defined by the statute means an individual’s address, telephone number, or
social security number.
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signature
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2 | P a g e
SERVICE AGREEMENT
I. PURPOSE: City of Rollingwood is responsible for protecting the drinking water supply from
contamination or 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. This utility enforces these restrictions to ensure the public health and
welfare. Each customer must sign this Service Agreement before we 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 Service Agreement.
II. PLUMBING RESTRICTIONS: The following undesirable plumbing practices are prohibited by
State regulations.
A. No Direct-connection between the public drinking water supply and 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 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 than 8.2% 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.
III. PLUMBING RESTRICTIONS: The following are the terms of the Service Agreement between
the City of Rollingwood and _______________________________.
Resident Signature
A. The Water System will maintain a copy of this Service Agreement as long as the customer and/or
premises is connected to the Water System.
B. The Customer shall allow his property to be inspected for possible cross-connections and other
unacceptable plumbing practices. These inspections shall be conducted by the District or its
designated agent prior to initiating new water service; when there is reason to believe that cross-
connections or other unacceptable plumbing practices exist; or after any major changes to the
private plumbing facilities. The inspections shall be conducted during the District’s 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 reinspection.
D. The Customer shall immediately correct any undesirable plumbing practice on his premises.
E. The Customer shall, at his expense, property install, test, and maintain any backflow prevention
device required by the Water System. Copies of all testing and maintenance records shall be
provided to the Water System.
IV. 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 expenses associated
with the enforcement of this Service Agreement shall be billed to the Customer.
3 | P a g e
SERVICE AGREEMENT
Property Address:
____________________________________________________________________
Street City State Zip Code
Do you have any of the following?
___________ Irrigation System
___________ Pool
___________ Hot Tub
___________ Water Softener
You must notify The City of Rollingwood if any of the above are installed after move in. If any of
the above are noticed at the time of turn on, the City of Rollingwood will not turn on service until
all requirements are met.
__________________________ _____________________________ ______________
Resident Name (Print) Resident Signature Date
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signature
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4 | P a g e
Confidentiality
Under the Texas Public Information Act, personal information in the City of Rollingwood’s utility
customer records is generally considered public information. The Texas Utilities Code, Chapter
182, provides that a government-operated utility may not disclose information in its utility
customer account records if the customer requests confidentiality* of the customer’s address,
telephone number, social security number, information relating to the volume or units of utility
usage, and the amounts billed to or collected for utility usage.
I REQUEST CONFIDENTIALITY OF MY PERSONAL INFORMATION, INCLUDING MY
ADDRESS, TELEPHONE NUMBER, SOCIAL SECURITY NUMBER, AND UTILITY
USAGE, BILLING, AND COLLECTION INFORMATION.
Name (Please Print)
Account Number
If you have requested confidentiality in the past, you also have the right to cancel that confidentiality
request by providing to the City of Rollingwood written permission to disclose personal
information.
Check the following if you wish to authorize the release your address and telephone
number to the following groups:
Rollingwood Women’s Club
Disclaimer
*A request for confidentiality does not prohibit a government-operated facility from disclosing the
information described above to :
1) An official or employee of the state, a political subdivision of the state, or the United States acting in an
official capacity;
2) An employee of a utility action in connection with the employee’s duties;
3) A consumer reporting agency;
4) A contractor or subcontractor approved by and providing services to the utility, the state, a political
subdivision of the state, or the United States;
5) A person to whom the customer has contractually waived confidentiality of personal information; or
6) Another entity that provides water, wastewater, sewer, gas, garbage, electricity, or drainage services
for compensation.
5 | P a g e
Emergency Management Notification System Registration
The City of Rollingwood has implemented the SwiftReach, Swift911™ emergency notification
system to communicate with residents and business owners during major events and
emergencies. This program is a powerful tool to inform and protect you and your family. Your
information remains completely confidential, and will only be used during designated situations.
To enroll your household or entity, please fill out the following information:
Primary Contact Name (Please print)_____________________________________________
Service Address (Please
Print)_________________________________________________Rollingwood, Texas 78746
Modes of Contact:
1. (_____)____________________ Receives Text? Yes No
Primary Phone Cell Phone? Yes
No
2. (_____)____________________ Receives Text? Yes No
Cell Phone? Yes No
3. (_____)____________________ No
Receives Text? Yes
Cell Phone? Yes
No
Email Address 1: ________________________________________
Email Address 2: ________________________________________
Email Address 3: ________________________________________
Emergency Notification System Opt Out
I ___________________________, wish to exercise my right to opt out of the emergency notification
system(SwiftReach and Swift911). In so doing, I understand my residence/business will not receive
any recorded phone or email notifications sent by the City of Rollingwood.
I acknowledge that these notices may include the following: natural disaster notifications; water utility
notifications including but not limited to water line breaks and boil water notices; any other urgent
notices designated by the City of Rollingwood.
I acknowledge and accept that failure to receive these notices may result in risk to my health and/or
safety.
___________________________________ ________________________________
Signature Date
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APPLICATION FOR WATER AND SEWER SERVICE (City of Rollingwood)

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Completed 24 January 2021

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