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WATER AND WASTEWATER CONNECTION REQUEST FOR SERVICE

  1. PROJECT LOCATED*

  2. WILL PROPERTY REQUIRE A REPLAT, SUBDIVISION, OR A LOT SPLIT? *

  3. (Residential, Multi-Family, Commercial, Retail, etc.)

  4. If the file doesn't upload, it can be emailed to gcarnahan@cityhs.net

  5. A formal engineering design may be required for more complex proposals.

  6. (i.e. number of lots, number of restrooms, number of bedrooms, number of office workers, number of customers and/or average daily water use, etc.)

  7. A review of the system model will be required if the project includes an equivalent of or more than 20 single family homes; or If the Utility Director or City Engineer determine that the pressure or capacity in this location may not be adequate for the project.

  8. SELECT ALL THAT APPLY*

  9. TERMS OF ACCEPTANCE AND ELECTRONIC SIGNATURE

    I, the [applicant, requestor, etc.] for this form, warrant the truthfulness of the information provided in this request for service. I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.

  10. ACKNOWLEDGEMENT*

  11. QUESTIONS?

    Call 501-321-6861

  12. STAFF USE ONLY

  13. DATE APPLICATION RECEIVED

    _________________________________________

  14. BY

    ________________________________________

  15. DATE APPLICATION APPROVED

    ________________________________________

  16. BY

    ________________________________________

  17. DATE APPLICATION DENIED

    ________________________________________

  18. BY

    _________________________________________

  19. DATE REQUESTED ADDITIONAL INFORMATION

    ________________________________________

  20. BY

    ________________________________________

  21. COMMENTS

    _____________________________________________________________________________________________

  22. Leave This Blank:

  23. This field is not part of the form submission.