General Information:

Applicant

* indicates a required field













Co-applicant














Service Address

Mailing Address


Previous Mailing Address


Service

Backflow / Cross Connection Service Questionnaire

Please make a selection

[text* Residence?]

If so, will it have (check all that apply)

InGround Swimming Pool / Hot Tub

Lawn Irrigation  

Fire System  

Waterfront Property  

Will this facility be used as a commercial place of business? *

If so, will it have (check all that apply)

InGround Swimming Pool / Hot Tub

Lawn Irrigation  

Fire System  

Waterfront Property  

If you have checked any item above, it is necessary that you install a backflow prevention assembly appropriate for the designated use prior to water being turned on to property. A Backflow/Crossconnection Inspector will call you within 24 business hours to provide you with additional information.

Once your information is submitted, a Customer Service Representative will contact you within 24 hours during normal business hours. Services are connected during normal weekday business hours.

I agree to not hold Roanoke Rapids Sanitary District or any other agent or representative thereof responsible for any damage that potentially could occur from having my water service turned on at the above referenced property. Roanoke Rapids Sanitary District shall not be liable for damage of any kind whatsoever resulting from turn on of water service or the use of water on the user's permises, unless such damage results directly from negligence on the part of Roanoke Rapids Sanitary District. Roanoke Rapids Sanitary District shall not be repsonsible for any damages done or resulting from any defect, leak, or broken lines in the piping, fixtures or appliances on the user's premises.

Roanoke Rapids Sanitary District recommends that a responsible person is at the home when water service is turned on, it is your responsibility to ensure that all water faucets are off and there are no leaks during the turn on procedure. If you have a hand gate valve on your waterline it is highly recommended the valves are in the off position.

Should your gate valve not be secured or functioning properly, a tap/spigot open, or a toilet running water, your water will be turned back off and the meter locked. If a second trip turn on is requested, a $50.00 service call will be assessed. If the second trip turn on is requested after 2loop_angle00 PM in addition to the $50 service call fee, a $55.00 after hours fee will be assessed.

Acknowledgment Disclosure*

Acknowledgment Disclosure I have read and agree to the Acknowledgement Disclosure