Application for New Water or Wastewater Service

THIS IS NOT A PERMIT. Additional permits and inspections may be required and are the responsibility of the customer. ALL APPLICABLE FIELDS ARE REQUIRED.

This form is also available in PDF format here: New Water or Wastewater Service Form

Customer Information

Customer Name

Phone

Cell Phone

Fax

Billing Address (if different than service address)

City

State

Zip

Service Address

Service Location

City

State

Zip

Project Information

Project Name

Plumber/Contractor

Parcel Number

Development Type

Service Information

Service Type

Domestic Service

Service Size & Meter Size

Irrigation Service

Service Size & Meter Size

Fire Service

Waterwater Service

Service Size & Meter Size

I agree that the information on this application is correct to the best of my knowledge. I understand that any changes made to the above information or attached documents may increase the time and costs required for the Holland BPW to provide service to the project. Charges for services rendered will go to the property owner of record or to the person who will be responsible for paying the utility bill at the address being served (Customer). Initial installation charges may appear on the first bill for service. I acknowledge that I understand and agree to the Terms and Conditions for Water Service and/or for Sewer Service, available at hollandbpw.com. Applications that are incomplete after 60 days may be discarded. For customers in the Township: Fees are paid to the Township, but commodity billing will be from the Holland BPW.

Customer or Authorized Representative

Signature

Confirm: