ACSA New Service Connection Fee Request Form

Date: *

Applicant Name: *

Contact Person: *

Contact Phone: *

Contact Email: *

Applicant Address: *

Applicant Address:

City

State/Province

Zip/Postal

Address of Proposed Service (Tax Map and Parcel below if no assigned address):

City

State/Province

Zip/Postal

Tax Map and Parcel: *

Subdivision: *

Lot Number:

Building Permit Number:

Service Type: *

Water Supply: *

Sewage Disposal: *

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.