Owner’s written permission for tenant to have water service at this address.
(Failure by the owner to approve and return this form, within 10 days, will result in
termination of service until form has been received by the Water Division)
I/we, the undersigned owner(s) of the property listed on this application agree to water service being
initiated as requested. I/we further acknowledge that water bills not paid by the applicant are my/our
responsibility and I/we agree to pay those water bills and any other charges incidental to terminating
service for non-payment. I/we also acknowledge that payment delinquency can result in the property being
ineligible for the Service Line Insurance Program should a leak occur.
I/we acknowledge as owner(s) that even if the property listed below is covered by the Service Line
Insurance Program, any water damage or other consequence of a leaking service line or any property or
personal injury resulting from my service line, stop box, curb stop (t-head) or other water appurtenance or
any associated depression or holes are my/our responsibility and I/we do not hold the City of St. Louis
Water Division liable.
I/we, the property owner(s) of the service address listed below agree to the terms and conditions of the City
of St. Louis Water Division.
SERVICE ADDRESS ZIPCODE
Signature of Property Owner(s): _______________________________________ Date: ________
PROPERTY OWNER NAME
MAILING ADDRESS
CITY STATE ZIPCODE
TELEPHONE NUMBER
( )
The owner of this property must sign and return this application within 10 days to:
Water Division Customer Service
1640 S. Kingshighway Blvd.
St. Louis, MO 63110
(Form CS1 – 04/2013)
