PRE-APPLICATION FORM FOR RURAL WATER SERVICE
(EQUAL OPPORTUNITY PROVIDER)

NOTE:  A non-refundable administrative fee of $50 is due with this application.  The SW Regional District will consult with their engineering firm to determine the proper line size and connection point.  A cost estimate will be completed once engineering reviews, field conditions, material cost quotes and contracted excavation bids are available.  Most cost estimates are done within 4 to 6 weeks and results may indicate that the District cannot provide service to restricted areas located within its system.  The Southwest Regional Water District will require all construction-service connection estimates to be pre-paid prior to the start of construction and for a 5-Year Water Service Agreement to be completed-signed by the new applicant.

DATE ___________NAME OF APPLICANT _________________________

MAILING ADDRESS ___________________________

______________________________________________

HOME PHONE NO. __________________WORK PHONE NO. ___________________

NAME OF PROPERTY OWNER __________________________________________

LOCATION OF WATER METER SERVICE:

911 ADDRESS _____________________________________________

COUNTY ___________TOWNSHIP ______________ SECTION ____

SIZE OF WATER SERVICE REQUESTED: (check one)
HOME USE-RESIDENTIAL ____COMMERCIAL FARM USE ____INDUSTRIAL LARGE USE ____

Please attach the legal description of the property location where the water service is to be installed.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

“The following information is requested by the Federal Government in order to monitor compliance with Federal Laws prohibiting discrimination against applicants seeking to participate in this program.  You are not required to furnish this information, but are encouraged to do so.  This information will not be used in evaluating your application or to discriminate against you in any way.  However, if you choose not to furnish it, we are required to note the race/national origin of individual applicants on the basis of visual observation or surname.”

ETHNICITY:RACE: (Mark one or more)
    Hispanic or Latino ____                        White ____ Black or African American ____   
    Not Hispanic or Latino ____        American Indian/Alaska Native ____ Asian ____
       Native Hawaiian or Other Pacific Islander ____
GENDER:  Male ____   Female ____