Step 1 of 2 50% Application for Water Tap or Service APPLICANT AGREES TO: Comply with JACKSON COUNTY UTILITY DISTRICT’S rules, regulations, and policies. Pay promptly at such rates, time and place as determined by the UTILITY’S governing body. Comply with the requirements of the Tennessee Department of Health that the applicant’s existing water system will in no way be connected to the UTILITY’S lines, forming a cross-connection. This is to prevent contamination of the lines of the JACKSON COUNTY UTILITY DISTRICT. If applicant has a well or a spring, he must execute a well user’s agreement. Grant the UTILITY the right of ingress and egress necessary for the UTILITY to operate and maintain the water lines. Connect only one residence to each tap. Install, service and repair own line from meter to place of usage at own expense. Install pressure reducing valve on his line. (To supply water to all customers, the UTILITY carries more pressure than most household plumbing can withstand.) Be responsible for water flowing from his broken lines. Customer must install a low-pressure switch on their pump if their location may call for one. In case of a main line leak on the UTILITY side and a low-pressure condition happens the UTILITY will not be responsible for replacing the customer’s pump. Be responsible for damage to meters and boxes caused by applicant. The UTILITY makes no guarantees, expressed or implied, as to service quality, quantity, pressure, consistency or continuity. The UTILITY shall, at its discretion, specify how and what uses may be made of service provided to CUSTOMER. If the CUSTOMER fails to comply with the uses so specified, service shall be discontinued. Receive their first bill on the 1st of the following month if they receive service before the 25th of the month. Meters are read before the 15th of each month and bills are mailed at the end of each month. Bills are due and payable by the 11th of each month. Any bill not paid by the 11th will be charged a 10% penalty. Any bill not paid by the 11th will be locked for non-payment in approximately 7 days. To reinstate service, you must pay for water used up to the point of disconnection, plus all reconnection fee that applies. Not construct a fence between the meter and the road so that the meter reader cannot get to the meter. We do not Know what is in the fence and are not obligated to climb over fences. Leave enough area around landscaping or flowers planted near meter boxes for UTILITY to raise meter lids. The Utility is not responsible for damage to landscaping or flowers. The utility bills for services monthly, and bills are mail in bulk at the US Post office. The utility cannot guarantee the delivery of its bills. Failure to receive a bill does not relieve customer of payment or any late charges. Terms Agreement(Required) I have read and agree to the terms. Applicant Name(Required) First Last Phone(Required)This field is hidden when viewing the formDriver's License NumberAttach a Copy of Your Driver's License(Required)Accepted file types: jpg, jpeg, gif, png, pdf, heic, Max. file size: 10 MB.Attach a Copy of Your Deed / Lease Agreement(Required)Accepted file types: jpg, jpeg, gif, png, pdf, heic, Max. file size: 10 MB.Email(Required) Enter Email Confirm Email Co-Applicant Name First Last Co-Applicant PhoneMailing Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Tap/Service Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you have a well or a spring? Please select the applicable checkbox(s). I have a well. I have a spring. I have neither of these. Well Users' Agreement In accordance with JACKSON COUNTY UTILITY DISTRICT’S cross connection control program, a private well or an auxiliary water source may NOT be connected in any manner to the public water supply unless proper protection against cross connection is provided. Only reduced pressure backflow preventers or approved air gaps may be used for protection. These devices must have prior approval by the JACKSON COUNTY UTILITY DISTRICT. Customers not in compliance With this rule will have their water service discontinued. This serves as notification that a well or spring may be utilized at this property. I (We) further understand and agree that this system is and shall remain totally segregated from the public water supply and no unapproved or unauthorized cross connections, auxiliary intakes, interconnections or by-passes will be permitted without the written approval of the JACKSON COUNTY UTILITY DISTRICT. I (We) further understand and agree that should an auxiliary water supply be connected to the public water system at this location, maximum cross connection control equipment in the form of an approved air gap or Reduced Backflow Prevention Device shall be installed to protect the public water supply.Is there any medical reason that service cannot be interrupted?(Required)Please Select...YesNoWritten verification from a medical doctor is required before meter can be labeled as non-cut-off. The water bill is still required to be paid in full by the disconnect date, but notification will be made prior to disconnect.What date would you like for services to begin?(Required) MM slash DD slash YYYY Signature(Required) 9304
