Application for Water Service 

 

Date:_________________

Subject always to the established rates, rules and regulations and any changes or amendments hereafter made.

I, the undersigned  ÿ Owner ÿ Tenant of the property at ________________________

Hereby make application for a supply of water at said premises with service to begin_______________.  And to continue until cancelled by at least ten days written notice.  If I sublet, I will be responsible for any water and sewer charges left unpaid by tenants of the property listed above.

Approved:

The Municipal Authority of the Borough of Derry

Owner_______________________

     Per________________________

Tenant_______________________

Mail bill to: ___________________

                ___________________

 

* Please Print and return to the Main office at: 620 N. Chestnut St.  Derry, PA 15627

Note: You may have to adjust the margin settings before printing to obtain the whole document

 

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