HomeMy WebLinkAboutSDP202000051 Application 2020-11-09ALBEMARLE COUNTY SERVICE AUTHORITY
APPLICATION FOR UNDERGROUND IRRIGATION SYSTEM SERVICE
DATE OF APPLICATION: _____________
INCLUDE SKETCH OF SYSTEM DESIGN WITH APPLICATION. INDICATE PREFERRED
METER LOCATION AND FLOW RATES FOR ALL ZONES.
PROPERTY OWNER
NAME:
BILLING ADDRESS SERVICE ADDRESS/LOCATION
STREET: STREET:
CITY: CITY:
STATE: ZIP: STATE: ZIP:
SUBDIVISION:
LOT NUMBER:
TELEPHONE: WORK: ( ) HOME: ( )
CONTRACTOR INFORMATION
NAME:
ADDRESS:
TELEPHONE: WORK: ( ) MOBILE: ( )
SYSTEM INFORMATION
DESIRED DATE OF SERVICE:
AFFILIATED ACSA ACCOUNT NUMBER:
RANGE OF FLOW (GALLONS PER MINUTE)
MINIMUM:
MAXIMUM:
BACKFLOW PLUMBING PERMIT
NUMBER:
DATE ISSUED:
ESTIMATE (FOR ACSA USE)
FORWARDED
TO: DATE: DUE DATE:
METER SIZE:
INSTALLATION COST:
METER COST:
TOTAL COST:
ESTIMATE PROVIDED TO:
DATE: TIME:
COMMENTS: