ACSA New Service Connection Fee Request Form Request for Connection Fees (New Service) Date: * Applicant Name: * Contact Person: * Contact Phone: * Contact Email: * Applicant Address: * Applicant Address: Applicant Address: Applicant Address: City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Address of Proposed Service (Tax Map and Parcel below if no assigned address): Address of Proposed Service (Tax Map and Parcel below if no assigned address): Address of Proposed Service (Tax Map and Parcel below if no assigned address): Address of Proposed Service (Tax Map and Parcel below if no assigned address): City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Tax Map and Parcel: * Subdivision: * Lot Number: Building Permit Number: Service Type: * Residential Non-Residential Water Supply: * Public Private Sewage Disposal: * Public Private Total Number of Floors With Plumbing (including habitable areas above the upper floor) * Plumbing Fixture Count Worksheet Completed and will be e-mailed to engineering@serviceauthority.org (required for all non-residential meters and residential meters that serve more than one unit): * YES N/A Comments: Supporting Documentation Submission Instructions If you are required to submit a Plumbing Fixture Count Worksheet for your proposed service, please e-mail it to engineering@serviceauthority.org after submitting this form. Please place “Plumbing Fixture Count Worksheet” and the “Address of Work or Tax Map and Parcel Number” in the subject line. Thank you. If you are human, leave this field blank. Submit Δ