Private Well Application

Private Well Application
FORM:

PRIVATE WELL APPLICATION
Prior to completing this form, please read the Private Well Restrictions letter (this will open in a new window).
Acknowledgment*

By checking this box, I acknowledge that I have read the Private Well Restrictions letter attached in the link above.

NOTE: * indicates a required field
Delivery of Private Well Application:*

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The undersigned hereby requests permission from Atascadero Mutual Water Company (AMWC) to drill and use a new or replacement private well on the following parcel of land within the AMWC service area.
Applicant Information
Owner Name:*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone
Business Phone
Do you have a landline?*

YESNO
Home Phone
E-mail*
Fax Number

Terms and Conditions
I understand that AMWC reserves the right to deny permission to drill and use any new or replacement private well within the AMWC service area. I understand that I will be required to enter into a written agreement with AMWC before drilling the proposed well, and the agreement will be recorded against the real property on which the well is drilled. I understand that if a water main fronts or is otherwise available to serve the property, I will be required to connect to the AMWC water system, and pay all fees required for such connection, before drilling the proposed well.

Refer to Policy 1.5.6 Restrictions on Private Wells.pdf
Please check:*

I agree to the above Terms and Conditions
Name:
Property OwnerAuthorized Agent
Electronic Signature Agreement

By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By selecting "I Accept" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature, or any resulting agreement between you and AMWC. In addition, you are confirming that you are the shareholder authorized to enter into this Agreement.
I Accept*

By checking this box and typing my name below, I agree to the terms and conditions of the Electronic Signature Agreement, and I am electronically signing my application.
First Name*
Middle Initial
Last Name*
Date*

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Date
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