Application for New Service Fill out form and you will be contacted with connect fee and deposit information.Customer Name*Service AddressService Address*City*SubdivisionBlock/LotBilling AddressBilling Address is the Same as Service Address* Yes No Billing AddressCityStateZip CodeDaytime Phone Number*Alternate Phone NumberEmail Address*Driver's License #*Date of Birth*ex. 01/02/1993Social Security Number*Requested Connection Date* Date Format: MM slash DD slash YYYY ORBIT SYSTEMS, INC. SERVICE AGREEMENTORBIT SYSTEMS, INC. SERVICE AGREEMENT1. Orbit Systems, Inc. is responsible for protecting the drinking water supply from contamination or pollution which could result from improper plumbing practices. The purpose of this service agreement is to notify each customer of the plumbing 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 Orbit Systems, Inc. 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. 2. Applicants for water service where service has not been previously provided must submit a completed Customer Service Inspection certificate signed by a licensed inspector prior to service being initiated to certify that there are no cross connections or other potential sources of contamination. Failure to submit the completed form is grounds for termination of service. 3. The following undesirable plumbing practices are prohibited by state regulations. a. No direct connection between the public drinking water supply and 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. b. 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. c. No connection which allows water to be returned to the public drinking water supply is permitted. d. 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 provided water for human use. e. 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. 4. The following are the terms of the service agreement between Orbit Systems, Inc. and ________________________________. a. Orbit systems, Inc. will maintain a copy of this agreement as long as the customer and/or the premises is connected to the water system. b. The customer shall allow his property to be inspected for possible cross connections and other undesirable plumbing practices. These inspections will be conducted by the water system or its designated agent prior to initiating service and periodically thereafter. The inspections shall be conducted during the water systems normal business hours. c. Orbit Systems, Inc. shall notify the customer in writing of any cross-connection or other undesirable plumbing practice which has been identified during the initial inspection or the periodic re-inspection. d. The customer shall immediately correct any undesirable plumbing practice on his premises. e. 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 by the water system. f. One meter is required for each residential, commercial, and industrial connection. All water sold by the utility will be billed based on meter measurements. The utility will provide, install, own and maintain meters to measure amounts of water consumed by its customers. As per Section 2.09- Meter Requirements, Readings, and Testing of Orbit Systems, Inc. Water Tariff 5. The customer shall allow a 10 ft. utility easement on his property in line with existing Orbit Systems, Inc. distribution system property. 6. If the customer fails to comply with the terms of the service agreement, Orbit Systems, Inc. shall, at its option either terminate service or properly install, test, and maintain an appropriate backflow device at the service connection. Any expenses associated with the enforcement of this agreement shall be billed to the Customer.Acknowledgement Acceptance* Yes I acknowledge and accept the terms of service as listed above.
