CITY HALL, FINANCE DEPARTMENT, 200 H STREET, corner of 3
rd
& H Street, Antioch, Ca 94509
Telephone: 925.779.7060 Fax: 925.779.7054 customer-service@ci.antioch.ca.us
NEW WATER ACCOUNT APPLICATION
RESIDENT TYPE: OWNER TENANT
SERVICE ADDRESS:
APPLICANT NAME:
CO-APPLICANT NAME(s):
(as listed on Deed or Lease Agreement)
MAILING ADDRESS:
(if different from service address)
Driver’s License No(s):
Social Security No(s):
Cell Phone: Home Phone:
Email Address:
Employer name/address:
APPLICANT ACKNOWLEDGEMENT:
I hereby acknowledge the following:
• I request water service at the premise designated and agree to pay at the rate as prescribed by the City’s
Water/Sewer Ordinance and Master Fee Schedule (subject to change).
• If water is off: It is MY RESPONSIBILTY to make sure ALL the faucets and fixtures on the property are in the OFF
position. The City of Antioch will turn water ON whether I am present at the property or not and is not liable
for any property damage or usage caused by failure to ensure all water sources are turned OFF
• I shall be responsible for all water service usage and service charges relating to this service address until the
date I notify the City of Antioch requesting discontinuation of these services. Failure to request
discontinuation of service will result in my being billed for any water usage/charges until I officially close the
account in my name
• A minimum deposit of $186 will be required for water service, pursuant to the Antioch Municipal Code 6-5.12,
if I am a new tenant, if I’ve had an account go to collections, or if my previous account(s) had delinquency
notices issued
• A Water Setup fee of $30, along with valid government ID, are required to start service
• All bills not received by the City of Antioch by the due date will incur a 5% late fee based on current charges
• Failure to pay my monthly bills could result in water service suspension, delinquency notices, calls, texts or
emails, and subsequent fees associated with suspended services
Applicant Signature: Date:
Co-applicant signature: Date:
