HIDE Business Builder's Application - H2GO Brunswick Regional Water & Sewer Services

Hours of Operation 9 AM - 5 PM

Phone 910-371-9949

After Hours Emergencies Water 910-367-1537 Sewer 910-367-2084

Hours of Operation 9 AM - 5 PM

Phone 910-371-9949

After Hours Emergencies Water 910-367-1537 Sewer 910-367-2084

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Business Builder's Application

Business Name:

Federal Tax ID #:

Name Of Owner:

Owner's Birthday:

Driver's License #:

State:

Mailing Address:

City:

State:

Zip:

Service Address:

Lot #:

Sub-Division:

Town:

Telephone:

Home No:

Office No:

Cell No:

I agree to pay the Brunswick Regional Water & Sewer monthly charges as computed by the monthly rate schedule in effect at the time of usage and initial hook up fees as described below:

	Water	Irrigation	Sewer
1. Meter
2. Tap Fee
3. Impact Fee
4. Sec Deposit
5. Admin Fee		(NON REFUNDABLE)
6. Capitol Rec
7. Grayson Ext

Total Charges ($)

Signature:

Date:

Does this property need a Grinder Pump? (Y/N):

Engineered Plans & Specs

Approval From State (Y/N)

Easements/Row (Y/N)

Deed & Dedication (Y/N)

THE ABOVE MUST BE PROVIDED TO BRUNSWICK REGIONAL WATER AND SEWER BEFORE METERS CAN BE SET