Fillable WATER & SEWAGE SYSTEM APPLICATION & CONNECTION PERMIT (City of Winchester)

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WATER & SEWAGE SYSTEM APPLICATION & CONNECTION PERMIT (City of Winchester)

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Country of origin: US
File type: PDF

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Rouss City Hall
Telephone: (540) 667-1815
15 North Cameron Street
FAX:
(540) 662-5803
Winchester, VA 22601
Website:
www.winchesterva.gov
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.
APPLICANT INFORMATION
Applicant’s Name:
Service address:
City:
State:
ZIP Code:
Date of Birth:
Do you Own or Rent?
Own:
Rent:
Have you had Service before?
Yes:
No:
If yes to above (what location & when):
Mailing address (if different from service address):
City:
State:
ZIP Code:
Email:
OTHER INFORMATION
Property Located:
In-City:
Out-City:
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
in the tenant’s name.
Owner’s Name:
Address:
Phone:
City:
State:
Zip Code:
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:
Date:
APPROVED BY (Public Services Department)
Date:
FOR OFFICE USE ONLY
Account Number:
Date:
Deposit Received:
Yes(Date)
No
“To provide a safe, vibrant, sustainable community while striving to constantly improve the quality of life for
our citizens and economic partners.”
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WATER & SEWAGE SYSTEM APPLICATION & CONNECTION PERMIT (City of Winchester)

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Completed 22 March 2021

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