Owner's Name
*
First Name
Last Name
Contractor (if applicable)
Service Type
*
Commercial; Water/Sewer
Commercial; Irrigation (Water Only)
Residential; Water/Sewer
Residential; Irrigation (Water Only)
Request Type
*
New
Rebuild
Service Location Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Lot Number
*
Parcel Number
*
Driveway Location Marked
*
Yes
No
Commercial Only - Engineered stamped plans approved by Broad Creek PSD
Yes
No
Billing Primary Contact Name
*
First Name
Last Name
Billing Primary Contact Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Mobile Number
Please enter a valid phone number.
Format: (000) 000-0000.
Home Number
Please enter a valid phone number.
Format: (000) 000-0000.
Applicable Fees (See Fee Schedule Below)
Meter Size
*
Please Select
5/8"
3/4"
1"
2"
3"
4"
6"
8"
N/A
Sewer Line Size
*
Please Select
4"
6"
N/A
Water Connection Fee
*
Please Select
$1,700
$2,000
$3,100
$4,500
$5,300
$10,400
$12,500
N/A
Sewer Connection Fee
*
Please Select
$430
$1,720
N/A
Water Capacity Fee
Please Select
$975
$1,465
$2,440
$7,800
$14,625
$24,375
$48,750
$78,000
Does not apply to rebuilt.
Sewer Capacity Fee
Please Select
$2,425
$3,635
$6,055
$19,385
$36,345
$60,575
$121,150
$193,835
Does not apply to rebuilt.
Total Capacity Fees
*
Total Connection Fees
*
Residential Construction Deposit ($150)
*
Total Fees Due
*
Signature
*
By signing my name above I understand and agree to each and all of the Terms and Conditions in this form. My electronic signature is legally binding.
Date
*
-
Month
-
Day
Year
Date
Submit
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