Mailing Address:_______________________________________________
/State/Zip:______________________________________________ Email Address#:________________________________
ephone:_____________________________Cell/Home/Work Alt. Ph.______________________________Cell/Home/Work
Pool? ______Yes_____ No Sprinkler System? _____Yes _____No Owner_____Renter______
Deposit Amount:____$200.00______ Cash____________ Check #______________ Credit Card:_____________
sfer From:_____________________________________________ Start Date:_____________________________________
cant Signature:_________________________________________________________________________________________
(Circle one)
lity Account #:____________________________________ Tax Account #:________________________________
ce Address:________________________________________________________________________________________
Condo N
ame:___________________________________________________ Unit #:_______________________________
or Owner:___________________________________________________________________________________________
Meter Number:______________________________ Previous Read:______________ Final Read: ______________________
Service Street Address:
(Circle one)
Utility Confidentiality Form – US-1000-03-00-2
Page 1 of 3
October 2018
I. PURPOSE. The City of Horseshoe Bay (City) is responsiblefor protecting the drinking water supply from contamination or pollution which could result
from improper water and/or sewer 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 City enforces these restrictions to ensure the public health and welfare. Each customer must sign this
agreement before the City will begin service. Inaddition, when service to an existing connection has been changed, suspended or terminated, the City
will not re-establish service unless it has a signed copy of this 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 a potential source of contamination is permitted. Potential sources of
contamination shall be isolated from the City's 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 than 8.0% lead may be used forthe installation or repair of plumbing at any connection which provides
water for human use.
E. No solder or flux which contains more than
0.2percent lead can be used for the installation or repair of plumbing at any connection which provides
water for human use.
F. All connections to the City water system must have plumbing systems in compliance with the current Uniform Plumbing Code and the
City's Cross Connection Control Plan.
The provisions of the current Standard Plumbing Code shall apply to every plumbing installation, including alterations, repairs, replacement,
equipment, appliances, fixtures, fittings, and appurtenances, when connected to the City's water or sewage system.
A person, firm or corporation shall not install, repair, alter, enlarge, remove, move, improve, convert, or demolish any plumbing system connected
to the City's water or sewer system without first obtaining a permit from the City. Ordinary minor repairs may be made with the approval of the
City Inspector without a permit, provided that such repairs shall not violate any of the provisions of the adopted plumbing code.
Each connection must have passed inspection by the City authorized Plumbing Inspector to be provided water service.
III. SERVICE AGREEMENT. The following are the terms of the service agreement between the City and (the Customer) who is responsible for paying for
services provided.
A. The City will maintain a copy of this agreement as long as the Customer and/or the premises is connected to the facilities of the City.
B. The Customer shall allow his property to be inspected for possible cross-connections and other undesirable plumbing practices or functions. These
inspections shall be conducted by the City personnel prior to initiating service and periodically thereafter. The inspections shall be conducted
during the City's normal business hours.
C. The City shall notify the Customer in writing of any cross-connection or other undesirable plumbing practice or functions which has been
identified during the initial inspection or the periodic re-inspection.
D. The Customer shall at his expense immediately correct any undesirable plumbing practice on the premises.
E. The Customer shall at his expense, properly install, test, and maintain any backflow prevention device required by the City. Copies of all testing
and maintenance records shall be provided to the City.
IV. ENFORCEMENT. If the Customer fails to comply with the terms of the Service Agreement, the City 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
agreement shall be billed to the Customer.
Service Location Customer’s Signature
P.O. BOX 7765 Horseshoe Bay, TX 78657 (830)598-8741
Start Date
Utility Confidentiality Form – US-1000-03-00-2
Page 2 of 3
October 2018
NAME: ___________________________________________ PHONE: ____________________________
ADDRESS: __________________________________________________________________________________
CITY: ________________________________ STATE: ___________ ZIP CODE: ____________________
SERVICE ADDRESS: _______________________________________________
E-MAIL ADDRESS: _________________________________________________
EMERGENCY CONTACT W/PHONE NUMBER: ____________________________________________________
In accordance with Subchapter B of the Texas State Utility Code Title 4, (TSUC), Texas Codes > Utilities Code >Title 4 >
Subtitle B > Chapter 182 > Subchapter B - Confidentiality of Customer Information
A citizen has the right to request confidentiality of certain "Personal Information" on a customer's account record. Personal
Information is described as "an individual's address, telephone number, or SS #. Subpart 182.052 Confidentiality of Personal
Information states the request must be in writing. A customer may rescind a request for confidentiality by providing the City
with written permission to disclose personal information.
TSUC Subchapter 182.054, Exceptions states that the subchapter does not prohibit the City from disclosing personal
information in a customer's account record to: (1) an official or employee of the state, a political subdivision of the state, or
the U.S. acting in an official capacity; (2) an employee of a utility acting 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 U.S.; (5) a person for whom the customer has contractually waived confidentiality for
personal information; or (6) another entity that provides water, wastewater, sewer, gas, garbage, electricity, or drainage
service for compensation.
I hereby request that my "personal information" as described in the paragraph above and as defined in Subpart 182 of the
TSUC, be held as confidential information. I have read and understand the information above. I agree to provide the City
with a written release should I choose to rescind this document.
Initial here for POA Exception.
POA Exception: I hereby request that my phone number, name and address be released to the Horseshoe Bay POA for
publication in the Horseshoe Bay POA phone directory.
Date of Request Signature of Applicant
RECEIVED BY UTILITY DEPARTMENT ON: __________________________ DATE RECORDED: _________
SIGNATURE OF UTILITY CLERK: _______________________________________
Please email the completed form to
Utility Confidentiality Form – US-1000-03-00-2
Page 3 of 3
October 2018