New Services Inquiry

Thank you for applying to Aquarion Water Company for water service. Please fill in the pertinent information.

Upon submitting this form you will receive an email confirmation and your request will be reviewed.
  Property Address
 
    *Street Number 
    *Street Name 
    *City
    *State
    *Zip
 -   
 
  Requestor's Information
 
    *Requestor's First / Last Name
    
    *Call Back Number
 -   -   Ext.   
    *Email Address
(We will never disclose your email address)
 
    *Relationship to Property
 Owner
 
    *Other
 
  Property Owner's Information
 
    *Property Owner's Name
    *Mailing Address
     
    *City
    *State
    *Zip
 -   
    *Phone
 -   -   Ext.   
     Email
(We will never disclose your email address)
   
  
  Intended Use Of This Property
   
 *(Please check all applicable boxes)
  Residential   
   
Single
Family 		    Multi-Family /
Multi-Unit
  Subdivision   
  Commercial   
  Industrial   
  Public Authority   
  Combination Residential / Commercial
   
  
  What Are Your Needs?
   
 *(Please check all applicable boxes)
  Domestic Water Supply to Building
  Lawn Irrigation
  Fire Service / Sprinkler   
  Hydrant
  Other
*
   
  
  Building Information
   
  
    *Does the building have frontage
 on a State Road? (i.e., State Route
 25 aka Main Street, Monroe)
Yes   No    I don’t know
   
  
    *Nearest cross street
   
  
    *Distance from street to the
 building
 Feet
   
  
    *Number of bedrooms
 Bedroom(s)
   
  
    *Required Gallons Per Minute
 (GPM), if known
 GPM       Unknown   
   
  
    *Building length
 Feet
   
  
    *Building width
 Feet
   
  
    *Number of floors
 Floor(s)
   
  
    *Number of units
 Unit(s)
   
  
    *Is there an existing building?
Yes   No
   
  
    *Is the building being
 demolished?
Yes   No
   
  
  Well Information
   
  
    *Is this property currently on
 a well?
Yes   No
   
  
    *Has the well failed?
Yes   No
   
  
    *Do you plan to keep the well?
Yes   No   I don’t know
   
  
  Attachments Including Maps, Pictures, Drawings and Sketches (Optional)
   
  
 
 
 
 
  Comments (Optional)
   
  
 
 
Note: * Indicates required fields