Administration • Finance
362 N. Third Avenue • Stayton, OR 97383
Phone: (503) 769-3425 • Fax (503) 769-1456
Services Order #___________
WATER ON REQUEST
Today’s Date: ______________ Account #: _______________
Turn On Date: _______________ Meter Read: ____________
Customer Name: ____________________________________
Business Name: ____________________________________
Services Address: ___________________________________
Mailing Address: ___________________________________
Phone Number: ___________________________________
Email Address: ___________________________________
Renting Buying
A $200 DEPOSIT and $40 Service Charge must be collected
at the time a customer signs, up for Water and Sewer Services
Deposit Date: ___________ Amount: __________ Waived BY: ______
Verify Title/Rent Contract: _______________ Ext/PP: _____________
Transfer Balance from Acc#: __________ Transfer Date: ___________
Owner Name: _________________ Phone #:_________
Mailing Address: _________________________________
"This Institution is an equal opportunity provider"
