Application for New Service

Step 1 of 4

25%

Effective Date*
Full Applicant Name*
First Middle Last
Co-Applicant Name, if applicable
First Middle Last
Applicant Email*
Phone*
Mailing Address*
Address City State ZIP Code
SS# or Fed Tax ID#*
Drivers License#
Applicant Date of Birth*
Previous Property Owner*
First Last
Property Location*
Town*
Map & Lot*
Type of Service*
- Residential
- Commercial
- Government
Effective Date of Service*
Residential
Residential Type*
- Single Family
- Rental
- Apartment
- Condo
- Duplex
Seasonal?*
- Yes
- No
Please describe seasonal meter location explaining where customer wants service line to run:*
Will there be a Pressure Tank/Booster Pump installed on public water supply?*
- Yes
- No
Will there be:*
- Fire Protection
- Pool
- Underground Irrigation (Requires Separate Line)
- None of the Above
Commercial
Note: When calculating demand and flow, seasonal customers are to base calculations on one-hundred and eighty (180) day season.
Business Name:*
Peak Demand (gpm)*
Peak Daily Flow (gpd)*
Peak Pressure Need (psi)*
Ave. Demand (gpm)*
Ave. Daily Flow (gpd)*
Ave. Pressure Need (psi)*
Peak Flow Season*
Peak Months
Seasonal?*
- Yes
- Now
Sprinkler System Required?*
- Yes
- Now
(for fire protection)
Sprinkler Line Size*
Water Use:*
Check Applicable
- Restraurant
- Entertainment
- Heavy Manufacturing
- Primary Food Processing
- Inn, Hotel, or Motel
- Professional (non-medical)
- Harvested Sea Products
- Irrigation
- Retail (non-perishable)
- Professional (medical)
- Agriculture
- Nursing Home
- Retail (perishable)
- Light Manufacturing
- Aquaculture
- Day Care
Please specify the percentage of property that is used for Business*
This is for Maine State Bureau of Taxation. All water used for business purposes is taxable.
Please specify the percentage of property that is used for Residential*
This is for Maine State Bureau of Taxation. All water used for business purposes is taxable.
Please Provide # of Fixtures
Kitchen Sink*
Dishwasher*
Washer*
Laundry Tub*
Outside Spigot*
Lavatory*
Bathtub/Shower*
Toilet with Flush Tank*
Toilet with Flush Valve*
Others: Please List
Government
Please Select Government Type*
- Local
- State
- Federal
- Quasi-Municipal
Water Use:*
Seasonal*
- Yes
- No
Fire Protection/Sprinkler Required*
- Yes
- No
Additional Information/Comments

Credit Information
Applicant Place of Employment or Source of Income*
Do you owe any outstanding bills for water?*
- Yes
- No
Do you owe any outstanding utility bills of any kind?*
- Yes
- No
Have you filed for bankruptcy within the past 6 years?*
- Yes
- No
Annual or Seasonal?*
- ANNUAL: Year round water service at the same premise. (Quarterly Billing)
- SEASONAL: Seasonal water use includes intermittent use, season after season, at the same premises. (Seasonal Billing)
Percentage Used for Business*
Please specify the percentage the property is used for Business purposes. This is for Maine State Bureau of Taxation. All water used for business purposes is taxable. If not completed, Commercial property will be taxed at 100% Must be broken down to nearest 10%.
Percentage Used for Personal*
Please specify the percentage the property is used for Business purposes. This is for Maine State Bureau of Taxation. All water used for business purposes is taxable. If not completed, Commercial property will be taxed at 100% Must be broken down to nearest 10%
Credit References (Businesses you have had credit with. Example: Electric Company, Fuel Company, Landlord.)
Credit Reference Name*
First Last
Contact Number*
Credit Reference Name*
First Last
Contact Number*
Credit Reference Name*
First Last
Contact Number*

Civil Rights Information Collection for USDA Financed Organizations

USDA financed facilities that use applications to determine eligibility for receipt of benefits or services or for informational purposes, will put the slogan "Equal Opportunity Program" on the bottom of their application forms and informational brochures.

Recipients using application forms shall establish a section at the end of the form, below the signature and date block or a separate card/sheet to collect race/national origin information. In addition, the following disclosure notice shall be included

"The following information is requested by the Federal Government in order to monitor compliance with Federal laws prohibiting discrimination against applicants seeking to participate in the program. You are not required to furnish this information but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race/nationality origin of individual applicants on the basis of visual observation or surname.
Race*
- White
- Black
- Hispanic
- American Indian or Alaskan Native
- Asian or Pacific Islander
- I prefer not to answer
Sex
- Male
- Female
- I prefer not to answer
Recipients using application forms will provide services and benefits in the order applications are received. A current waiting list will be maintained by the date and time an application is received, name of the applicant, race/national origin and a summary of the action taken

Above records will also reflect the number of applicants approved or rejected for the benefit or service by race/national origin. The recipient shall make a report of this information available to Rural Development employees, USDA officials, and other appropriate Federal employees, i.e., HUD or DOJ employees, as requested by telephone or written notice through an appropriate Rural Development Official.

Boothbay Region Water District Responsibilities
1. Supply of potable water.
2. Installation of meter and meter findings.
Applicant Responsibilities
1. Cost of the service line from the water main to the building, plumbing, including excavation, and any permits required (ie., Road Opening)
2. If required, cost of tapping of water main to be reimbursed to the District.
3. Read and comply with the Boothbay Region Water District's Terms and Conditions of Service
Release*
- I/We hereby give the Boothbay Region Water District permission to release any and all information which may be deemed necessary in order for collection of any outstanding debts I/We may occur to the Water District.
Terms & Conditions*
- I have read and understand the above. I have also downloaded a copy of the Terms and Conditions of Service. I authorize the Boothbay Region Water District to enter the premises and access the property to inspect the service installation, normal maintenance of the water meter, evaluate, require and test backflow prevention devices, and evaluate potential usage. I further understand the estimated cost is to be paid in advance and any adjustments will be made upon completion of the work.
Billing Agreement*
- I hereby contract with Boothbay Region Water District for water service and agree to pay for the same in accordance with the established rates of said Water District until written notice is given to discontinue said water service, and to conform to all Rules and Regulations of said Water District, now in force or which may hereafter be adopted, governing the use of water.
  I understand that should my property ever be rented, and the tenant has water service in their name(s) and fails to make full payment I, as the property owner, am responsible for payment and agree to indemnify and hold harmless the Boothbay Region Water District from any and all debts and costs of collection in connection with said debt.
Please Type Applicant Name to Serve as Electronic Signature*
Please Type Co-Applicant Name to Serve as Electronic Signature

Recent BRWD News

2018 Knickerbocker Lake Water Withdrawal Report – updated 13 August 2018

The Boothbay Region Water District began water withdrawals from Knickerbocker Lake per its NRPA permit issued by the Maine Department of Environmental … [Read More...]

Contact BRWD

Boothbay Region Water District
Adams Pond Road | PO Box 520
Boothbay ME 04537
207-633-4723 x 110
207-633-7921 fax

Facebook

Facebook Posts

View on Facebook

Boothbay Region Water District

3 months ago

2017 Consumer Confidence Report (CCR)- The 2017 CCR is now ready at the link below. The CCR is a recap of 2017 water quality and a pretty interesting read.

www.bbrwd.org/about/meetings/2011-consumer-confidence-report-2/ ... See MoreSee Less

View on Facebook

·Share

Pay Online

© 2018 Copyright · Boothbay Region Water Distric · All Rights Reserved · Website by Seaside Web Design, LLC ·This website contains material for informational purposes only. Any links to other websites are provided only for the purpose of convenience and do not constitute a referral or endorsement of any linked site or its owner. Boothbay Region Water District is not responsible for the contents of any linked site or any link contained in a linked site, or any changes or updates to such sites.

Application for New Service

Step 1 of 4

Residential

Commercial

Please Provide # of Fixtures

Government

Credit Information

Credit References (Businesses you have had credit with. Example: Electric Company, Fuel Company, Landlord.)

Civil Rights Information Collection for USDA Financed Organizations

Boothbay Region Water District Responsibilities

Applicant Responsibilities

Contact BRWD

Facebook

Facebook Posts

Pay Online