APPLICATION FOR SERVICE Complete and return this form with all required documents and information to: Scott County PSA 156 Legion Street Weber City, VA 24290 276-386-3401	OFFICE USE ONLY Received: _____/_____/20_____ Water Sewer Residential Non-Residential If Non-res., meter = ____-inch Connection fee paid: $________ Deposit paid: $________ Admin. Fee paid: $________ Account No. _______________ Meter No. _________________ Connected: ____/____/20____ Disconnected: ____/____/20____ Scanned: Staff initials: ______

Please mark all the appropriate boxes and fill in the required blanks:

Type of service:	☐ Water	☐ Sewer	Check one: ☐ Existing system ☐ New project Enter name of project
Type of connection:	☐ Residential	☐ Non-residential
☐Single family ☐Multi-unit	☐Single tenant ☐Multi-unit
Building status:	☐ Existing	☐ Not yet built	Enter occupancy date MM/DD/YYYY
Ownership status:	☐ I own this property	☐ I rent this property (If renting, owner must complete lower section.)
Applicant name:	Enter last name	Enter first name	Enter middle name
PSA account status:	☐ Have current account	☐ Had previous account	☐ Never a SCPSA customer
Service Address:	Enter street address/POB	Enter city	Enter state	Enter zip
Mailing Address: (If same, leave blank.)	Enter street address/POB	Enter city	Enter state	Enter zip
Telephone Nos.:	Enter primary phone number	Enter secondary phone number
Email address:	Enter email address
Security info:	Enter date of birth as MM/DD/YYYY	Enter Social Security Number
Driver’s License:	Enter State	Enter license number	Enter expiration date MM/DD/YYYY
Health certification: Code 15.2-5138(3)	☐ No applicable health issues	☐ Yes, and submitted health endangerment certification
Select bill delivery:	☐ Mail	☐ Email:	Enter email address
Choose payment:	☐ Mail, in-person, or online	Automatic bank draft (must complete separate ACH Authorization Form)

I, the above named Applicant, certify that the above information is correct and that I have read and agree to the “TERMS AND CONDITIONS FOR WATER AND SEWER SERVICE” on the reverse side of this form.

Applicant signature: ____________________________________________________________ Date: ____/____/20____

If the Applicant is leasing the property that is to be served, the property owner must complete this section:

Property Owner:	Enter last name	Enter first name	Enter middle name
Mailing Address:	Enter street address or POB	Enter City	Enter State	Enter zip
Telephone Nos.:	Enter primary phone number	Enter secondary phone number
Email address:	Enter email address

The above Applicant has entered into a lease for the property located at the above listed Service Address and I as Property Owner or authorized representative hereby authorize the Applicant to obtain water or sewer service at this address as a tenant.

Property owner signature: ____________________________________________________________ Date: ____/____/20____

TERMS AND CONDITIONS FOR WATER AND SEWER SERVICE

Customer will abide by Scott County Public Service Authority (SCPSA) Rules and Regulations, the SCPSA Cross Connection Control Program, applicable Scott County ordinances, the Virginia Plumbing Code, and the Uniform Statewide Building Code.

Customer will pay all SCPSA charges, including connection fee, deposit, administrative fee, monthly use charges, penalties and reconnection fees.

SCPSA will provide sufficient water and sewer system capacity to serve Customer’s connection, including a minimum pressure of 20 psi at customer’s water meter under normal conditions as required by state regulations.

SCPSA will mail bills before the 1st of each month. Customer payment is due the 10th of each month and SCPSA will assess a 10% penalty if payment is made after the 10th of the month. SCPSA will disconnect service if a bill is not paid by the 20th of the following month.

Customer will allow SCPSA to inspect the customer’s water and sewer plumbing at any reasonable time deemed necessary by SCPSA to verify there are no cross connections or other hazards to the SCPSA water or sewer system.

Customer will keep their water meter and the first sewer cleanout accessible at all times and will give SCPSA the right of ingress and egress to the meter or the first sewer cleanout for the purpose of meter reading, cross-connection prevention, sampling, repair and maintenance of SCPSA lines and equipment, or other necessary operations.

Customer will install and maintain all plumbing on the customer’s side of the water meter or sewer tap (unless installed by SCPSA as part of a new waterline project). This includes installing (1) the water service line to the SCPSA meter, plus any PRV or cutoff valve required by the building code on the customer’s side of the water meter, and (2) the sewer service line (at a minimum slope of 1/8 inch per foot) to the SCPSA sewer tap; and repairing leaks in the customer’s plumbing.

Customer will contact SCPSA prior to backfilling and covering Customer’s new water or sewer service line. This is for SCPSA’s benefit to allow SCPSA to inspect the connection of the water or sewer service line. This inspection does not replace any inspection required by the Scott County Building Official.

Customer will disconnect all private sources of water (wells, springs, cisterns, etc.) from the building plumbing before connecting to the SCPSA meter.

Customer will prohibit extension of the customer’s service line to serve additional customers. All customer connections must have a separate SCPSA meter or a separate sewer tap.

SCPSA has a Water Leak Adjustment Policy with the following main stipulations: (1) The leak must be on the customer side of the meter; (2) The customer must request the adjustment after repairing the leak; (3) The leak must have caused the water usage to exceed 3 times the normal usage; (4) The adjustment may be applied to two consecutive months; and (5) A leak adjustment may only be done once in 12 months.

Customer will inform SCPSA of any changes to their account, including name and billing address changes.

Customer will prevent the discharge of the following into the SCPSA sewer system: storm water, surface water, groundwater, roof runoff, swimming pool discharge, and condensate. This includes discharges from sources of runoff, rain, or groundwater including sump pumps, gutters, downspouts, and storm drains.

Customer will prevent the discharge of materials into the SCPSA sewer that are harmful to the SCPSA sewer system and the wastewater treatment processes, including greases, oils, petroleum products, flammable liquids, corrosive liquids, toxic chemicals, pesticides, and solids with a dimension larger than ½-inch.

Customer must sign and submit the SCPSA form “Authorization to Turn On Water Service Waiver and Release of Liability”.