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2. NOTE:

   Do not use this form to sign up for water/sewer/refuse service. This form is for a water/sewer tap for new construction or replacing an existing water/sewer tap.
   

   Complete the online form here for Residential Water, Sewer, and Refuse Collection Services.

4. Address of tap location*
6. PROPERTY OWNER'S INFORMATION
7. APPLICANT/DEVELOPER'S INFORMATION
9. Name*
10. Name
12. Address*
13. Address
15. City, State, Zip*
16. City, State, Zip
18. Applicant/Developer's Relationship to Owner*

20. WATER SERVICE

21. SEWER SERVICE

23. Tap size and number of service(s) requested
24. Tap size and number of service(s) requested
26. Date when tap(s) are desired/needed
27. Date when tap(s) are desired/needed
29. Is this the first tap for the parcel/address?

    1. Yes
    2. No

    1. N/A
30. Is this the fist tap for the parcel/address?

    1. Yes
    2. No

    1. N/A
32. Is this a replacement of existing tap(s)?

    1. Yes
    2. No

    1. N/A
33. Is this a replacement of existing tap(s)?

    1. Yes
    2. No

    1. N/A
35. Additional tap for parcel?

    1. Yes
    2. No

    1. N/A

    (please explain below)

36. Additional tap for parcel?

    1. Yes
    2. No

    1. N/A

    (please explain below)

38. Is this for a sprinkler system or fire line only?

    1. Yes
    2. No

    1. N/A
40. Is this a water service for landscaping irrigation?

    1. Yes
    2. No

    1. N/A
42. Is this a conversion of a single meter to dual memter?

    1. Yes
    2. No

    1. N/A
44. Check yes if taps installed by developer as a part of new construction, tap fees/deposits do jnot apply (explain below); all meters will be installed by City staff with the material costs for meters being billed to and paid for by the developer.*

    1. Yes
    2. No
46. Explanation

48. The undersigned hereby agrees to pay all connection charges (costs incurred for the taps). Said charges shall include materials used, equipment rentals, contract services, and labor costs as actually incurred by the City. If such costs are higher than the deposit amount the applicant shall immediately reimburse the City for all connection charges in excess of the deposit amount. If the cost is less than the deposit amount, the City agrees to reimburse the applicant the deposit amount in excess of the connection charges. Upon request and approval, connection charges may be paid in no more than 24 installment payments at the rate of 7% per annum with a minimum of 10% of the total connection charges due immediately.

    NOTE: An assessment fee for the City-owned water and/or sewer main lines may be required in addition to connection charges. Also in addition to the tap deposit fee, service deposit(s) will be required for the monthly service fee(s) prior to the service(s) being turned on or activated.

50. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
52. Electronic Signature of Applicant*
53. Date*
55. STANDARD CONNECTION SIZES AND DEPOSIT INFORMATION

    Water service tap sizes and water tap deposit fees:

    5/8"	1"	1-1/2"	2"	3"	4"	Larger
    $750	$800	$2,600	$2,800	$3,800	$4,200	**

    
    

    4" and 6" sewer service taps (location of sewer main) and sewer tap deposit fee:

    Grass/no pavement	Gravel	Oil & chip	Concrete or asphalt	Brick	Other
    $900	$1,300	$2,000	$2,400	$3,000	**

    
    

    **Contact the City's Engineering Department for more information at 618-457-3270.

57. Once your application has been approved by the City, you will receive a secure link from noreply-pay24x7@openedge.com in which to pay your application fee.

59. Please choose how you prefer to receive the secure link:*

    1. Email
    2. Text
60. Email*
61. Cell Phone*
Leave This Blank:


64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit

* indicates a required field