COLONIAL BEACH, VIRGINIA 22443

(804) 224-0880

R E Q U E S T F O R W A T E R S E R V I C E

Water Service is hereby requested for a single family dwelling unit on Lot Described as TAX MAP NUMBER _______________________, WITH A 911 STREET ADDRESS OF ______________________________ in Placid Bay Estates A connection, tap, accommodation, and impact fee of $8200.00 for new connections. Application for any previously purchased tap, which has not been billed continuously for water service, must be accompanied by an impact fee of $1000.00 for each year of non use or a new tap fee, whichever is lower. I have reviewed a copy of the Rules, Rates, and Regulations and understand that rates may change from time to time. Meter, meter box, and valves are company facilities and a fee will be charged for damage to same. Customer will be responsible for usage due to breaks in his line. Any plumbing, connected to water service line, must meet code and must be connected, BY A VIRGINIA LICENSED PLUMBER, in a manner which does not negatively impact water service facilities in any way. MANY INSTALLATIONS REQUIRE UP TO 120 DAYS FROM RECEIPT OF APPLICATION TO COMPLETION OF INSTALLATION. PLEASE PLAN ACCORDINGLY FOR UNEXPECTED DELAYS. PBE WATER SUPPLY IS NOT ABLE TO MODIFY APPLICATIONS. INCOMPLETE APPLICATIONS WILL BE RETURNED TO APPLICANT.

SERVICE LINE: SERVICE LINE MUST BE A MINIMUM OF 160 PSI POLYETHYLENE OR POLYBUTYLENE & MUST BE CONNECTED TO METER COUPLING, BY A VIRGINIA LICENSED PLUMBER, ONLY WITH APPROVED BRASS FITTINGS (NO PLASTIC OR NYLON). A READILY ACCESSIBLE SHUTOFF VALVE MUST BE INSTALLED IN THE SERVICE LINE IMMEDIATELY ADJACENT TO WHERE THE SERVICE LINE ENTERS THE FOUNDATION.

EXPANSION TANKS FOR WATER HEATERS: THE PLUMBING CODE REQUIRES WATER HEATER EXPANSION TANKS TO BE INSTALLED ON CLOSED SYSTEMS. MAIN SERVICE TAPS IN PLACID BAY ESTATES ARE OPEN SYSTEMS. ANY BUILDER INSTALLING A WATER HEATER EXPANSION TANK MUST ALSO INSTALL, EITHER A CHECK VALVE, OR A DOUBLE CHECK BACKFLOW PREVENTION DEVICE ON THE SERVICE LINE, IN ORDER TO MAKE THE HOUSE PLUMBING A "CLOSED SYSTEM", AND THEREBY PREVENTING BACKFLOW THROUGH THE METERED SERVICE CONNECTION.

I will be responsible for this account, even if sold, until PBE Water Supply is provided with the complete name and mailing address, or email address, of new owners, IMMEDIATELY AT CLOSING DATE, and the account is paid in full. I further understand that billing will start on the connection date requested below, or as soon as installation of tap is completed. Minimum Billing is continuous with no credit given for periods of vacancy, seasonal/vacation cutoffs or periods of restricted water service. PBE Water Supply does not handle seasonal or vacation temporary interruptions of service. A main valve is required to be installed at the point of entry to the foundation or house, for temporary cutoffs by the homeowner.

NAME OF VA LICENSED PLUMBER (CONNECTING SERVICE LINE) _________________________________________________VA CONTRACTOR LICENSE NUMBER ______________________

AFTER CONNECTION IS COMPLETED TO METER AND TO HOUSE BY YOUR VA LICENSED PLUMBER, AN INSPECTION MAY BE REQUESTED BY EMAIL TO HELP@PBEWATER.COM. ONCE INSTALLATION IS APPROVED, SERVICE WILL BE ACTIVATED AND/OR METER SET

_______________________________________ __________________________________

ACCOUNT NAME PHONE NUMBER

_______________________________________ __________________________________

BILLING ADDRESS EMAIL ADDRESS

_______________________________________ __________________________________

CITY, STATE, ZIP 911 SERVICE ADDRESS (MUST BE SHOWN ON APPLICATION)

__________________ $__________________ __________________________

DATE TOTAL FEE ENCLOSED DESIRED CONNECTION DATE

(ALLOW at least 120 DAYS, 180 days under certain circumstances)

________________________________________

SIGNATURE OF APPLICANT

A 911 STREET ADDRESS, A WORKING EMAIL ADDRESS, AND REAL METAL SURVEYOR'S PINS, ARE REQUIRED PRIOR TO OUR SCHEDULING, OR MARKING THE LOCATION OF, YOUR INSTALLATION.

ACCOUNT BILLING WILL START WITHIN 30 DAYS AFTER INSTALLATION .

EVERY ATTEMPT WILL BE MADE TO COMPLETE TAP INSTALLATIONS WITHIN 120 DAYS OF RECEIPT OF COMPLETED (911 ADDRESS REQUIRED) APPLICATION (180 DAYS UNDER UNUSUAL CIRCUMSTANCES, PROVIDED THAT UNEXPECTED DELAYS ARE NOT ENCOUNTERED. HELP TO INSURE A TIMELY INSTALLATION BY DIALLING 811 FOR A MISS UTILITY TICKET PRIOR TO CLEARING YOUR LOT (WE WILL BE NOTIFIED OF YOUR INTENTIONS TO BUILD), BY TRYING TO PREVENT THE OBLITERATION OF MISS UTILITY MARKINGS NEAR YOUR SITE, BY KEEPING AREA OF TAP INSTALLATION CLEAR OF CONSTRUCTION DEBRIS AND PORTA POTTIES, BY INSURING THAT REAL METAL SURVEYOR'S PINS WITH COLORED FLAGGING ARE VISIBLE AT FRONT & REAR LOT CORNERS, BY HAVING A 911 ADDRESS ON APPLICATION, AND BY PROVIDING A WORKING EMAIL ADDRESS ON THE APPLICATION. FAILURE TO FOLLOW THESE GUIDELINES WILL ADD DRASTICALLY TO THE TIME REQUIRED TO COMPLETE YOUR INSTALLATION AND WILL PUT IT ON HOLD UNTIL IT IS COMPLETE. On-site contractor MUST provide proper drainage around proposed location of meter box and proper grading and stump removal must be completed prior to the installation of tap. Taps will not be installed or activated without proper grading away from the proposed meter box site at Builder's Expense.

Call Miss Utility of Virginia 48 hours prior to beginning lot clearing. Dial 811 or call toll free 1-800-552-7001.

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