Water Utilities Application

Water Utilities Application
Address for which you are applying service:
Mailing Address (if different than above):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Account Holder*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Drivers License #*
DL State*
Social Security Number*
Primary Phone*
Please enter a valid phone number.
Secondary Phone*
Please enter a valid phone number.
Email*
example@example.com
Employer's Name*
Secondary Account Holder:

First NameLast Name
Date of Birth

MonthDayYear
Date
Drivers License #
DL State
Social Security Number
Primary Phone
Please enter a valid phone number.
Secondary Phone
Please enter a valid phone number.
Email
example@example.com
Employers Name
For Commercial Account: Business Name
Would you like to receive your bill via email?

YesNo
Would you like to have your bill auto-drafted?

YesNo
Have you ever had Water Utilities with the City of Mineola?

YesNo
If yes, when?

MonthDayYear
Date
What was the address?
Your Emergency Contact Name:

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.

The above information is true to the best of my knowledge. Water service may be disconnected should information provided on this application not be true and correct. I further agree, in the event of non-payment, I will be charged per Mineola Code of Ordinances Section 44-24.

$30.00	each Reconnect Fee	$25.00	each Disconnect Fee, Transfer Fee
$150.00	each Meter Deposit (Residential)	$200.00	each Meter Deposit (Commercial)

It shall be unlawful for any person in any way to injure any meter box, or curb box, or, after the water of any customer has been cut off by the city, to turn the water back on to said customer, without the written permission of the City. Mineola Code of Ordinances Section 44-31.

Payment for water utility bill is due on the 10th day of the month or assessed a late penalty of 10% or a minimum of $10. Call for a hearing before the cut-off day which is the 21st day of the month.

Signature

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Water Utility Service Agreement

300 Greenville Hwy Mineola, TX 75773 903-569-6183 903-569-6551 fax www.mineola.com
§290.47(b) Service Agreement

I. PURPOSE. The Mineola Water Department is responsible for protecting the drinking water supply from contamination or pollution which could result from improper private water distribution system construction or configuration.

The purpose of this service agreement is to notify each customer of the restrictions which are in place to provide this protection. The utility enforces these restrictions to ensure the public health and welfare. Each customer must sign this agreement before the Mineola Water Department will begin service. In addition, when service to an existing connection has been suspended or terminated, the water system will not re-establish service unless it has a signed copy of this agreement.

II. RESTRICTIONS. The following unacceptable practices are prohibited by State regulations.
1. No direct connection between the public drinking water supply and a potential source of contamination is permitted. Potential sources of contamination shall be isolated from the public water system by an air-gap or an appropriate backflow prevention device.
2. No cross-connection between the public drinking water supply and a private water system is permitted. These potential threats to the public drinking water supply shall be eliminated at the service connection by the installation of an air-gap or a reduced pressure-zone backflow prevention device.
3. No connection which allows water to be returned to the public drinking water supply is permitted.
4. No pipe or pipe fitting which contains more than 0.25% lead may be used for the installation or repair of plumbing at any connection which provides water for human use.
5. No solder or flux which contains more than 0.2% lead can be used for the installation or repair of plumbing at any connection which provides water for human use.
III. SERVICE AGREEMENT. The following are the terms of the service agreement between the Mineola Water Department (the Water System) and, blanks* , (the Customer).
1. The Water System will maintain a copy of this agreement as long as the Customer and/or the premises are connected to the Water System.
2. The Customer shall allow his property to be inspected for possible cross-connections and other potential contamination hazards. These inspections shall be conducted by the Water System or its designated agent prior to initiating new water service; when there is reason to believe that cross- connections or other potential contamination hazards exist; or after any major changes to the private water distribution facilities. The inspections shall be conducted during the Water Systems normal business hours.
3. The Water System shall notify the Customer in writing of any cross-connection or other potential contamination hazard which has been identified during the initial inspection or the periodic re-inspection.
4. The Customer shall immediately remove or adequately isolate any potential cross-connections or other potential contamination hazards on his premises.
5. The Customer shall, at his expense, properly install, test, and maintain any backflow prevention device required by the Water System. Copies of all testing and maintenance records shall be provided to the Water System.
IV. ENFORCEMENT. If the Customer fails to comply with the terms of the Service Agreement, the Water System shall, at its option, terminate service or properly install, test, and maintain an appropriate backflow shall, at its option, terminate service or properly install, test, and maintain an appropriate backflow prevention device at the service connection., Any expenses associated with the enforcement of this agreement shall be billed to the Customer.
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Water Utilities Application

Water Utility Service Agreement