Kingston Water Department Forms

Water Department Forms
Form Type:*
New Water Application
DATE CONNECTED:

MonthDayYear
Date
ACCOUNT #:
AMOUNT PAID OR BILLED:
DATE FINALLED:

MonthDayYear
Date
DATE CLOSED:

MonthDayYear
Date
NAME:*

First NameLast Name
BUSINESS NAME (IF APPLICABLE):
SERVICE ADDRESS:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MAILING ADDRESS: (IF DIFFERENT)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
OWNERSHIP:*

OWNERLANDLORDRENTER
LEASE DATE

MonthDayYear
Date
PHONE #1:*
Format: (000) 000-0000.
PHONE #2:*
Format: (000) 000-0000.
EMAIL:*
example@example.com
DRIVERS LICENSE NUMBER OR ID NUMBER:*
SSN#*
DATE OF BIRTH:*

MonthDayYear
Date
STATE:*
METER:
TRANSPONDER #:
SERVICES:
Would you want to be contacted by email or text concerning your account or water issues?*

EmailTextNeither
Would you like to receive your bills by email instead of mail?*

YesNo
Is there any medical reason that service cannot be interrupted?*

YesNo
Written verification from a medical doctor is required before meter can be labeled as non-cut-off. The water bill is still required to be paid in full, but notification will be made prior to disconnect.
Voluntary Information for Federal Grant
RACE ETHNICITY:
HISPANIC/LATINO

YesNo
The undersigned hereby makes application for service at the above address and agrees to pay for said service as measured by the System's meters, according to the System's Standard Rules and Regulations and further agrees, that if bill becomes delinquent and must be sent to Collection Agency, will be responsible for all costs incurred for the Collection Services. The applicant agrees to be responsible for all water consumed upon the premises from the date of installation and to permit authorized agents of the System free access to the premises of the consumer for the purpose of inspecting, reading, examining, repairing, or removing meters or other property belonging to the System. The applicant shall provide the necessary space on or in its premises for the location, safe keeping and protection of pipe, devices, meters, and meter boxes. The applicant shall see that at all times the meter and meter box be accessible to the meter readers or other employees of the Kingston Water Department (This includes landscaping, fences, and parked vehicles).

**FAILURE TO RECEIVE BILL DOES NOT RELIEVE CONSUMER OF PAYMENT AND PENALTY**

The applicant is strictly forbidden to interfere with the meters or other appliances of the Utility.

The applicant agrees to pay a minimum cost of $200.00 for repair or replacement, if meter is tampered with, broken, or disabled in anyway.

The applicant agrees to notify the Kingston Water Department in writing when they desire services to be discontinued and agrees to pay for all services for a reasonable time after such notice, in order to permit KWD to read or remove meter and render bill.
Signature*
APPLICANT ACKNOWLEDGES RECEIPT OF LEAK PROTECTION POLICY INFORMATION*
APPLICANT ACKNOWLEDGES RECEIPT OF INFORMATION REGARDING PAYMENTS, PENALTIES, DISCONNECT FOR NON-PAYMENT AND FEES ASSOCIATED FOR RECONNECT*
APPLICANT ACKNOWLEDGES THAT ACCOUNT OPENED AFTER READ DATE WILL BE ISSUED A MINIMUM BILL APPROXIMATELY*
POLICIES AND PROCEDURES - Click the last button at the bottom of the page here: https://kingstontn.gov/water-department-2/
Water Disconnect Application:
Name:*

First NameLast Name
Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Email:*
example@example.com
Today's Date:*

MonthDayYear
Date
Account Number:*
Property Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Disconnect:*

MonthDayYear
Date
Cross-Connection Survey
Occupant Name

First NameLast Name
Occupant Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupancy

OwnRent
Meter Serves

HomesBuildings
If homes, how many?
If buildings, how many?
Do you have? (Please check all that apply)

Hot tubWaterbedSwimming PoolSolar SystemJacuzziGreen HouseDarkroom EquipmentPortable Dialysis MachineUnderground Sprinkler SystemDrip/Soaker/Irrigation SystemInsecticide Sprayers (that attach to garden hose also)Utility sink w/ threaded faucet
Do you have a bathtub that fills from the bottom?

YesNo
Do you have a water softener of any extra water treatment system?

YesNo
Do you have an auxiliary water supply on your premises?

YesNo
Do you have livestock and use a water trough or water system connected to by public water?

YesNo
Is your home or building elevated above your water meter?

YesNo
Does a creek, river, or spring water run near or on your property?

YesNo
Do you have a booster pump, well pump, or any other type water pump?

YesNo
Do you receive irrigation water from a different source?

YesNo
Do you have a back flow protection device on your property now?

YesNo
Do you have any situation that you are aware of that could create a cross-connection?

YesNo
Do you have any other water-using equipment on your property not mentioned above?

YesNo
If yes, please list below:
Print Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Signature
Date

MonthDayYear
Date
Forwarding Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Connected:*

MonthDayYear
Date
Should be Empty:

Water Department Forms

New Water Application

Voluntary Information for Federal Grant

Water Disconnect Application:

Cross-Connection Survey