If same as applicant, continue onto service location. If renting property, renter's agreement must accompany this application.

Water Service Location
Location where service will be activated

ResidentialCommercialGovernmentalResale CustomerIrrigation Only

By signing this application for service, applicant(s) acknowledge and agree to all conditions of form. Applicant(s) also agree that all information provided is true and accurate to best of the applicant's knowledge. If my account becomes assigned to a collection agency, I agree to pay all court costs, and attorney fees. I understand after final bill has been processed, I have up to 90 to pay before collection and credit report actions are taken.

I understand that if this account is left in default, after disconnection of service, Jefferson Utilities will send this account to a collection agency in which may be reflected on my credit report. Collection action will be taken once this account is 90 days in default.

Notice of Potential Thermal Expansion High Pressure
This utility uses check valve meter setters for the protection of both the customers & the utility from potential back flow or back siphonage from the customer’s service. This can result in a buildup of pressure in the customers piping due to thermal expansions arising from the customer’s hot water heater. The customer is advised to assure that a thermal expansion tank is installed in the customer’s piping system. The utility is not responsible for any cost associated with the installation or maintaining the thermal expansion protection equipment, nor is the utility liable for any damages to person or property arising from failure of thermal expansion protection equipment to work properly, or for the customer’s failure or refusal to install thermal expansion protection equipment.

The Undersigned:
1. I hereby authorize service to be established in my name at the property location indicated on the application and agree to pay service until discontinued by my request. Customer also agrees to notify billing department if any information has changed.

2. States that this application for water service is for immediate and continuous supply of water service to premises described and agrees to pay for all water metered and or un-metered, and delivered to the customers service pipe for these premises.

3. Affirms that if the applicant moves from the premises and would like to have water service discontinued in their name, they must notify Jefferson Utilities in writing to have service discontinued and a final meter reading to be done. This must be done at least (3) three business days before a final meter reading is requested. Failure to do so will result in the applicant to be liable for any water used at the premises whether by them or someone else.

4. Understands that this application is accepted subject to the availability of service to this location.

5. Agrees to notify Jefferson Utilities (in writing) no less than (3) three working days in advance when a water meter is being requested to be set for new service.

6. Affirms that the applicant is responsible for any damage and all repairs to water meter, electronic reading device, meter setter, meter box or meter box cover resulting from accident, tampering, operating valve, or intentional vandalism of Jefferson Utilities Inc. / Valley Water and Services Inc. metering facilities.

7. Affirms that if applicant falls into termination state resulting in full termination a $25.00 disconnect fee will be applied to account. If Jefferson Utilities Inc. / Valley Water & Sewer Services Inc. receives a total of two returned checks, checks will no longer be accepted from applicant.

8. Understands that payment are due in the office by 4:30pm on the “due date”. We do not recognize “post marks” as a received date. You may make payments by cash, check, money order or credit card in our lobby Monday – Friday (8am – 5pm), drive-thru Monday – Friday (8am – 4pm), night drop after hours or online with Visa, Mastercard, or Discover Card at

9. Rates based off approved tariff P.S.C. Va Tariff No 7, shown on Original Sheet No. 4:
< First 3,000 gallons used per month at $11.04 per 1,000 gallons < Next 3,000 gallons used per month at $8.86 per 1,000 gallons < Next 4,000 gallons used per month at $7.25 per 1,000 gallons < Next 50,000 gallons used per month at $6.01 per 1,000 gallons < All over 60,000 gallons used per month at $6.01 per 1,000 gallons