CITY OF ELLSWORTH WATER DEPARTMENT
1 City Hall Plaza ▪ Ellsworth, ME 04605-1942
Phone (207) 667-8632 ▪ Fax (207) 667-4908
www.ellsworthmaine.gov
APPLICATION FOR WATER/SEWER SERVICE
Customer Name____________________________ Date of Birth______________________
Property Owner Name (If Tenant):________________________________________________
Service Address_______________________________________________________________ OWNER
Mailing Address_______________________________________________________________ TENANT
Driver’s License #______________________ Telephone #_______________________
Email Address_________________________________________________________________
PLEASE SELECT SERVICES FOR WHICH YOU ARE APPLYING:
WATER SEWER BOTH
If you have previously had water service in your name with the Ellsworth Water Department, please list service address:
____________________________________________________________________________
The intended water use is:
____Residential ____Combined Potable & Fire Protection
____Commercial ____Rental Property
____Industrial ____Fire Service 4” & Larger
____Number of Rental Units ____Other: Description_______________________________
PLEASE SELECT PREFERRED METHOD FOR BILLING DOCUMENTS:
PAPER EMAIL BOTH
THE OWNER/CUSTOMER FURTHER AGREES TO THE TERMS AND CONDITIONS AS FOLLOWS:
That the department by its representatives, shall have the right to enter the premises of the Applicant at a reasonable time for the purpose of making such inspections as it may deem necessary, and it shall
have the right to attach any testing device or use any means it may elect to ascertain the condition of the pipe and appurtenances and the uses made of same. That the extent of the rights of the applicant under this
Application is receive, such supply of water as shall then be available and no other or greater.
That the Applicant agrees that the department shall not be considered in any manner an insurer of property or persons, or to have undertaken to extinguish fire or to protect any persons or property against
loss or damage by fire, or otherwise and that it shall be free and exempt from any and all claims for damages on account of any injury to property or persons by cause whatsoever. That the rights and obligations of the
applicant hereunder shall be further subject at all times to the rates, rules, and regulations of the Department on file with the Maine Public Utilities Commissions & the Ellsworth Water Department’s Terms & Conditions,
that now exists or which may hereafter be adopted of file.
NOTE: A BACKFLOW PREVENTER WILL BE REQUIRED AT THE SERVICE ENTRANCE. RESIDENTIAL BACKFLOW PREVENTERS UP THROUGH 1” IN DIAMETER
DO NOT NORMALLY REQUIRE A PERMIT
Signature________________________________ Date___________________
Printed Name________________________________
Account#__________________
CID#______________________
Route#_____________________
