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HILTON CREEK COMMUNITY SERVICES DISTRICT

3222 CROWLEY LAKE DRIVE

CROWLEY LAKE, CA 93546

(760) 934-6299

APPLICATION FOR SEWER SERVICE

DATE OF APPLICATION:                                        _________________

APPLICANT’S NAME (Property Owner):            ______________________________

MAILING ADDRESS:                                        ______________________________

CITY, STATE, ZIP:                                                  ______________________________

DAYTIME TELEPHONE NO.:                                    _________________

IS THIS THE SAME AS THE PERSON TO WHOM THE BILLS SHOULD BE MAILED?   __________ IF NOT, CUSTOMER NAME: _______________________

MAILING ADDRESS: ___________________________________________________

LEGAL DESCRIPTION (ASSESSOR’S PARCEL NO.): _______________________

TYPE OF CONSTRUCTION:            __________________________________________

DESCRIPTION OF PROPOSED WORK TO CONNECT PREMISES TO DISTRICT’S SEWER SYSTEM: ___________________________________________

NAME OF PERSON/BUSINESS WHO WILL PERFORM WORK (must be a licensed contractor with appropriate insurance): ____________________________

**The District may require plans, specifications, drawings, or other such information as may be deemed necessary and the work must be performed in conformance with all of the District’s ordinances, regulations, specifications and requirements.

DATE APPLICANT WILL BE READY FOR INSPECTION:            __________________

HAVE PREMISES BEEN PREVIOUSLY SERVED BY THE DISTRICT? _________

HAVE CONNECTION CHARGES BEEN PREVIOUSLY PAID FOR PREMISES?

_______ IF SO, AMOUNT OF SUCH CHARGES: ___________DATE PAID:_____

If the customer designated above is other than the applicant, the applicant hereby agrees to guarantee payment of all Districts rates and charges incurred for service to his/her premises, agrees to be subject to District ordinances, rules and regulations governing sewer service, and agrees to be responsible jointly and severally with the designated customer for the payment of any delinquent bill.

Applicant hereby acknowledges that this completed application and the issuance of a sewer connection permit pursuant thereto is subject to District ordinances, rules and regulations including but not limited to, Ordinance No. 81-01, as amended, and Ordinance 2002-01.

_________________________________

Signature of Applicant

For completion by District:

CURRENT CONNECTION CHARGES DUE:              ________________________

CREDIT FOR PREVIOUSLY PAID CHARGES:                ________________________

TOTAL DUE FOR CONNECTION CHARGE:                  ________________________

PAID RECEIPT NO.:                                                   ________________________

INSPECTION FEE DUE:                                                  ________________________

CREDIT FOR PREVIOUSLY PAID FEE:                        ________________________

TOTAL DUE FOR INSPECTION FEE:                                    ________________________

PAID RECEIPT NO.:                                                   ________________________

**If customer is connecting to an existing lateral on the property, for which a connection charge has already been paid, there is no connection charge due. However, the connection must be inspected by the District and an Inspection Fee is due for this service.

DATE APPLICATION IS DETERMINED TO BE COMPLETE: ________________

________________________________________

DISTRICT REPRESENTATIVE SIGNATURE

 


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