DEVELOPER CONNECTION APPLICATION FORM

Application Fee Paid: $	 Date Paid:	 Check #:	 	Connection Fees Paid: $   Date Paid:	 Check #:		AFPI Charges Paid: $	 Date Paid:		 Check #:			
Grinder Pump Fee Paid: $		Meter Install Fees Paid: $		Water Meter Size: 		
Date Paid:		Date Paid:		Irrigation Meter Size: 		
Check #:		Check #:		Lot Acreage: 		

THIS SECTION IS FOR DISTRICT PERSONNEL USE ONLY

Application Date 	

Time 	AM/PM

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: 		
(Lots on East side require 1" Irrigation Meters)
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

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: