RESIDENTIAL APPLICATION – TOWN OF BRASELTON UTILITIES DEPT.
4986 Highway 53,  P.O. Box 306,   Braselton, Ga. 30517   Phone: 706-654-3915   Fax: 706-654-9100
 

 Services Applied For (check all that apply): 

Water

Sewer Reuse Transfer to Reuse

Note:  An application for reuse water service requires the execution of a separate agreement that must be attached to this application.   

If you are applying ONLY to have your existing irrigation meter transferred to our reuse system, you only need to fill out the highlighted areas of this application, and read and sign the attached agreement
.

A deposit is required for service.  Deposit amounts can be paid via cash, check, or money order or can be included on the first month’s bill.  The Town reserves the right to collect any outstanding utility bills owed to the Town by the applicant and payment of the deposit before the new service is established.  Applicants with Town accounts in good standing may have their existing deposit(s) transferred.


 

  Inside Town Limits Outside Town Limits
Meter Size Water Sewer Reuse Water Sewer
3/4" $65.00 $70.00 $35.00 $75.00 N/A
1" $120.00 $140.00 N/A $130.00 N/A
Deposits for larger meters shall be the Public Works Director’s estimate of 2 months of actual projected usage for that particular customer.


Three (3) days notice must be given in writing or in person to connect or disconnect service.  Application must be filled out completely, accurately and legibly (including property owner information) in order to establish your account and you must be at least 18 years old.  You may be required to provide a copy of your lease agreement, purchase agreement or picture ID. Customers must insure all inside plumbing is shut off.  Any damages as a result of open faucets or leaks inside the building are the customer’s responsibility. Any applications faxed after 5PM will be processed the next business day. (Weekends and Holidays are not included.) Only authorized personnel are allowed inside the meter box. If someone other than a Town employee damages the meter box or its contents, the customer of record will be responsible.  Any maintenance, turn ons, turn offs, or rereads will be done per customer request or during regular maintenance and reading schedules.  Charges for rereads and meter testing may apply.


First Name
Middle Initial/Maiden Name
Last Name
Date of Birth mm/dd/yyyy
Social Security # xxx-xx-xxxx
Driver's License #
State
Phone # (xxx) xxx-xxxx
Email Address xxx@xxxx.xxx
 
Service Address
City
State
Zip Code
Occupancy Date mm/dd/yyyy
Date You Desire Service mm/dd/yyyy
 
Mailing Address (if different)
City
State
Zip Code

Have you ever had services with the Town of Braselton Before? Yes   No
If yes, when and where?
 
Do you need a disconnect at a current address? Yes   No
Date of disconnect
Address (if different from above)
City
State
Zip Code

The Braselton Utility System receives Federal funds and is subject to compliance with equal opportunity requirements.
 
Type Service Requested: Water Sewer Both

The following information is requested by the Federal Government in order to monitor compliance with Federal Laws prohibiting discrimination against applicants looking to receive services. You are not required to provide 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/national origin of individual applicants on the basis or visual observation or surname.

White, not of Hispanic origin   Hispanic
Black, not of Hispanic origin    Asian or Pacific Islander
American Indian or Alaskan Native

The Town of Braselton Water & Wastewater System is an Equal Opportunity Program. Discrimination is prohibited by Federal Law. Complaints of discrimination may be filed with the Secretary of Agriculture, Washington D.C. 20250.


In applying for service, I verify that to the best of my knowledge the above information is correct. My signature indicates I have read all the above information.  I understand that providing false information may result in the rejection of my application or disconnection of services at a later date.


Signature: 

Date: 

mm/dd/yyyy