Pine Island Community Development District

WATER AND WASTEWATER UTILITIES POLICY MANUAL

DEVELOPER CONNECTION APPLICATION FORM

THIS SECTION IS FOR DISTRICT PERSONNEL USE ONLY

Application Date	Time	AM/PM	
Application Fee Paid: $	Connection Fees Paid: $	AFPI Charges Paid: $________	
Date Paid:	Date Paid:	Date Paid:	
Check #:	Check #:	Check #:	
Grinder Pump Fee Paid: $	Meter Install Fees Paid: $_____	Water Meter Size: __________	
Date Paid:	Date Paid:	Irrigation Meter Size: _______	
Check #:	Check #:	Lot Acreage: ______________	

TOTAL AMOUNT DUE: $

District Account # Given:

Anticipated Service Turn On Date:

Name of Person Taking Application:

Name of Person Receiving Payment:

Service Address:________________________________________________________________

Lot # or Legal Description (If No Address):__________________________________________

Applicant Info: (If a Business Please Provide Information for Authorized Representatives) Name of Applicant:
Name of Authorized Representative:				
Billing Address:			City/State:	Zip:	
Telephone Numbers: Work:_________________  Home:	Cell:	
Approximate Occupancy Date(s):	___________________________________________	
Type of Structure:		___________________________________________	
Type of Use:	Single-Family:	_________	Multi-Family: __________	
	Commercial:		_________	Other:	__________	
Number of Buildings: _________		Sq. Ft. per build./unit:	__________	
Number of Units:	_________		Potable Meter Size:	__________	
Lot Acreage:	_________		Irrigation Meter Size:	__________	

Applicable ERCs for Service: ________

Please refer to the District’s Water Utilities Policy Manual for assistance with ERC Computation.

If you are applying on behalf of the owner or leaseholder of the service address, below please indicate the name, addresses and contact numbers for the owner and leaseholders and attach sufficient documentation to this application evidencing your right to apply to connect service to the service address including a copy of the lease if applicable:

Owner Name:	_____________________________________________

Owner Address:	_____________________________________________
_____________________________________________

_____________________________________________

Contact #s:	___________ wk __________ hm ___________ cell

Revised Date:  December 13, 2012	35

Pine Island Community Development District

WATER AND WASTEWATER UTILITIES POLICY MANUAL

Lessee Name:	_____________________________________________

Lessee Address:	_____________________________________________

_____________________________________________
_____________________________________________

Contact #s:	___________ wk __________ hm ___________ cell

PROSPECTIVE DEVELOPERS ARE ADVISED THAT ALL SERVICE CONNECTIONS SHALL BE INSPECTED AND APPROVED BY BOTH THE LAKE COUNTY BUILDING DEPARTMENT AND THE DISTRICT AND THAT AT LEAST 48 HOURS NOTICE OF DESIRED INSPECTION TIME MUST BE GIVEN TO THE DISTRICT IN ORDER TO ACCOMMODATE SAME. FURTHER, IN ADDITION TO A CONNECTION FEE TO ESTABLISH A UTILITY CONNECTION TO A SERVICE ADDRESS, THERE MAY BE ADDITIONAL FEES CHARGED TO INSPECT A CONNECTION, FOR REVIEW OF PLANS, TO INSTALL A METER BOX AND OTHER CHARGES AND FEES IMPOSED IN CONNECTION WITH OTHER MISCELLANEOUS SERVICES PROVIDED BY THE DISTRICT WHICH SHALL BE BILLED AND PAID IN ACCORDANCE WITH THE ‘WATER UTILITIES POLICY MANUAL’ ADOPTED BY THE DISTRICT’S BOARD OF SUPERVISORS. A COPY OF THIS MANUAL SHOULD BE PROVIDED UPON PAYMENT OF THE APPLICATION FEE AND SHOULD BE READ AND UNDERSTOOD FULLY BEFORE ENGAGING THE DISTRICT’S UTILITY SERVICES.

APPLICANT’S SIGNATURE:_____________________________________________

CO-APPLICANT’S SIGNATURE:__________________________________________

Revised Date:  December 13, 2012	36