Request to Set Domestic Water Meter Request to Set Domestic Water Meter (Primary Service Activation) Date: * Business Name/ Resident Name: * Contact Name: * Contact Phone: * Contact Email: * Service Address: * Service Address: Service Address: Service 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 Billing Address: * Billing Address: Billing Address: Billing 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: * Service Type: * Residential Non-Residential Total Number of Floors With Plumbing (including habitable areas above the upper floor): * Number of Adults (if applicable): Number of Occupants (if applicable): This service will provide water to Medical Equipment that Requires Water:: * YES NO Building Permit Number: * Waterline Inspection Approval Date by County Inspections Office (if applicable): Sewerline Inspection Approval Date by County Inspections Office (if applicable): Backflow Inspection Approval Date by County Inspections Office (if applicable): I confirm that I have conducted a visual inspection of the water meter box/vault to ensure it is free of damage and meets the ACSA Construction Specifications. This inspection includes verification that the meter setter is centered, the meter setter is at the correct depth, the meter setter laying length is correct, the meter box/vault is at final grade and is free of mud and debris. * YES ** ** If the ACSA is unable to set the domestic water meter due to meter box/vault damage or non-compliance, a trip charge may be assessed. Description of current status/stage of building under construction: * Comments: If you are human, leave this field blank. Submit Δ
