City of Saint Louis
Water Division
Application for Water Service
The forms on the following pages must be filled out to establish an account with
the City of Saint Louis Water Division. There are 3 forms in this document:
1. The first is the application for water service. This must be filled out by the
Account Holder for the premises.
2. The second is the “Owner’s Written Permission” form. This must be filled
out by the property owner if the Account Holder is a tenant in the
premises. Owner occupied buildings do not need this form.
3. The third is the “Note of Responsibility.” This form must be filled out by
the Account Holder OR Owner of the premises before water will be turned
on.
FOR OFFICE USE ONLY: Cycle #____________ Bill from date: _______________
Processed by: __________ Billed deposit amount: $___________
City of St Louis Water Division Date: __________________
APPLICATION FOR WATER SERVICE
PLEASE PRINT New Acct No: __________________
BILLING NAME
SERVICE ADDRESS ZIPCODE
MAILING ADDRESS (If different from Service Address)
CITY STATE ZIPCODE
TELEPHONE NUMBER
( )
Last 4 digits of SS# OR Complete FED ID# OR Complete Driver’s License Number
Do you want duplicate bills sent to an address other than the service or mailing address? YES NO
If yes, please provide the following information:
NAME ADDRESS
CITY STATE ZIPCODE
Who will live at this address? TENANT OWNER
IF TENANT IS APPLYING FOR WATER SERVICE, THE PROPERTY OWNER MUST
AGREE TO TERMS AND SIGN THE BACK OF THIS APPLICATION
Type of Property: Residential: Single Family Duplex Condominium Other _________
Apartment Bldg: Number of Units _____
Commercial: Tax Exempt? YES NO If yes, please submit Tax Exemption Letter
If extra work is needed to restore or initiate service that is not covered by the turn-on fee or the Service Line Insurance Program
(if applicable) it will be the owner’s responsibility. In those cases, if extra work is necessary, I/we agree to pay the Water Division
for the extra services or contact a private plumber to make repairs to turn on water service.
Applicant Signature: _________________________________________ Date: _____________
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)
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