Residential Utility Service Request Form

You do hearby agree to pay your bill by the 10th of the month. You understand that you will not receive services until you have paid a seventy-five dollar ($75.00) deposit, and may be subject to a late charge if your bill is not paid by the due date. You also understand service may be disconnected if your bill is not paid by the 20th of the month. You understand that your deposit will be retained until service is disconnected and that the deposit will be applied against your final bill. I. PURPOSE: The City of De Leon is responsible for protecting the drinking water supply from contamination or pollution which could result from improper private water distribution system construction or configuration. The purpose of this service agreement is to notify each customer of the restrictions which are in place to provide this protection. The Utility enforces these restrictions to ensure the public health and welfare. Each customer must sign this agreement before the City of De Leon will begin service. In addition, when service to an existing connection has been suspended or terminated, the water system will not re-establish service unless it has a signed copy of this agreement. II. RESTRICTIONS: The following unacceptable practices are prohibited by state regulations. A. No direct connection between the public drinking water supply and a potential source of contamination is permitted. Potential sources of contamination shall be isolated from the public water system by an air-gap or an appropriate backflow prevention device. B. No cross-connection between the public drinking water supply and private water system is permitted. These potential threats to the public drinking water supply shall be eliminated at the service connection by the installation of an air-gap or a reduced pressure-zone backflow prevention device. C. No connection which allows water to be returned to the public drinking water supply is permitted. D. No pipe or pipe fitting which contains more than 0.25% lead can be used for the installation or repair of plumbing at any connection which provides water for human use. E. No solder or flux which contains more than 0.2% lead can be used for the installation or repair of plumbing at any connection which provides water for human use. III. SERVICE AGREEMENT: The following are the terms of the service agreement between the City of De Leon and said applicant. A. The City of De Leon will maintain a copy of this agreement as long as the customer and or the premises are connected to the City of De Leon. B. The Customer shall allow his property to be inspected for possible cross-connection and other potential contamination hazards. This inspection shall be conducted by the City of De Leon or its designated agent prior to initiating new water service, when there is reason to believe that cross-connections or other potential contamination hazards exist, or after any major changes to the private water distribution facilities. The inspections shall be conducted during the City of de Leon’s normal busines hours. C. The City of De Leon shall notify the customer in writing of any cross-connection or other potential contamination hazard which has been identified during the initial inspection or the periodic re-inspection. D. The customer shall immediately remove or adequately isolate any potential cross-connection or other potential contamination hazards on his premises. E. The customer shall, at his expense, properly install, test, and maintain any backflow prevention device required by the City of De Leon. IV. ENFORCEMENT: If the customer fails to comply with the terms of the Service Agreement, the City of de Leon shall, at its option, either terminate service or properly install, test, and maintain an appropriate backflow prevention device at the service connection. Any expenses associate with the enforcement of this agreement shall be billed to the customer. I have read, understand, and agree to all the above terms.