This form is for online submission application for Water, Wastewater and Solid Waste Services.
If you have any questions about this process, please contact the Finance Department at (209) 827-7000.
Today's Date * Date format: month/day/year (ex. 01/31/2016)
Name* (First and Last)
House Number* (enter a numerical value here)
Street Name* Be sure to include the correct ending (Ct., Way, Ln.). For streets beginning with a direction (e.g. W. J Street) be sure to include the street direction “N, S, E, W."
Unit Number (if applicable)
Mailing Address (if applicable)
Email Address * This is for our use only to contact you with confirmation and/or questions if needed.
Phone Number * Area Code and Number, ex. (209) XXX-XXXX. Again, for your use only if we need to contact you.
DL# and or Last four of SSN (For security purposes, please provide Requestor Driver License Number or Last Four Digits of SSN )
Notes (optional) Indicate any additional information you would like to provide
Customer Billing Information: * A. Utility charges are the legal responsibility of the above party, and any additional parties listed on the proof of ownership/lease agreement. A customer will remain responsible for any utility charges until a properly completed Application of Termination is accepted by the City Finance Department. B. Failure to pay such charges when due may result in disconnection of service. C. All utility bills will be mailed to the responsible party, at the address specified on this form. D. All customers are responsible for maintaining current information, including a current phone number.
Please Note: We will contact you after submission of this form. You will also be required to provide the following documents in order to start services: - Lease Agreement or Proof of Ownership - Current Photo ID - A $200 deposit is required to start services
By selecting this box you certify that the above billing contact information is correct; he/she has read and understands our policies and procedures. :
For verification purposes, please type in the text you see below: