HomeMy WebLinkAboutWPO202100060 Application 2022-08-15 (2)ALBEMARLE 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 ADDRESsILOCATION
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: