Water and Sewer Fee Determination – Customer Application Form

"*" indicates required fields

Address of Applicant:*
Address of Property to be served:*
Inside Martinsville City Limits (circle):*
If zoning and city limits information is unknown the Engineer will make the determination. Your application for service can be denied if the property is not properly zoned for the intended use.
Describe Use, including but not limited to: retail sales; general office; restaurant; including fast or carry out foods; grocery; convenient store; gasoline station; professional office, doctor, dentist, clinic, hospital or nursing home; barber or beauty shop; service club, church, civic or fraternal organization; school, college, daycare or library; stage or movie theater; hotel. motel, apartments (more than four units); assisted living or retirement center; car wash; self service laundry; correctional facility; jail or prison; industrial, manufacturing, warehousing, service or repair, dry cleaners, body shop, engine repair, brake/muffler, computer, electronics, contractors, or appliances; recreational facility, picnic areas, campground, racetrack, sport park, open-air stage. IF MULTIPLE USE DESCRIBE ALL USES!
Size of Water Meter requested:
If fire service connection required circle size:
Automatic Fire Sprinkles (circle):
Kitchen facilities:
A bar or bar area:
Shower or shower facilities: