Telephone: (540) 667-1815
WATER & SEWAGE SYSTEM
APPLICATION & CONNECTION PERMIT FORM
This permit application once signed & approved by the Public Services Department, will allow
the applicant to connect & receive water & wastewater services from the City of Winchester.
The below application must be completed in full.
Have you had Service before?
If yes to above (what location & when):
Mailing address (if different from service address):
Applicant’s Telephone Number:
Applicant’s Cell Phone Number:
Applicant’s Work Telephone Number:
If you are renting, please indicate Owner’s Name & Address Below & The City will also
need a Tenant Authorization Form signed by the Property Owner authorizing the bill to be put
THE UNDERSIGNED AGREES TO STRICTLY CONFORM TO THE LAWS & ORDINANCES RELATING TO
WATER & SEWER NOW IF EFFECT & ENACTED IN THE FUTURE (copy of ordinance available).
SIGNATURE OF APPLICANT:
APPROVED BY (Public Services Department)
“To provide a safe, vibrant, sustainable community while striving to constantly improve the quality of life for
our citizens and economic partners.”