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City of Oldsmar Application for Reclaimed Water and Hold Harmless Agreement

2. $320 Meter Installation fee
   Fee will become due upon submittal/processing of application

   Fee will become due upon submittal/processing of application

4. Service Address

5. Owner or Representative

6. Phone

8. Mailing Address

9. Email Address

11. RECLAIMED METERS ONLY: A five (5) foot separation must be maintained between a reclaimed and potable water line. Homeowner will be responsible for connecting their irrigation system to the City meter. Service is requested for: (Check applicable item)

13. Total Units:

14. Type

    1. Single-Family
    2. Apartment
    3. Condominium

15. Type

    1. Town Home
    2. Mobil Home
    3. Other

16. Are you...

    1. Commercial/Industrial

18. Name of Firm

19. Address

21. Type of Commercial/Industrial

22. Estimated water requirements: (average gpd) (peak demand/day)

26. What type of irrigation system you are presently using?

    1. In-ground
    2. Garden hose

27. Do you have a separate irrigation meter?

    1. Yes
    2. No

28. Do you have a well?

    1. Yes
    2. No

30. Type of Connection Requested:

    1. Hose-type Connection
    2. Irrigation System

31. Meter Size Requested:

33. It is understood and agreed that the Owner of the described premises shall be responsible for prompt payment to the City of Oldsmar, Florida, for all City utilities furnished by the City to the described premises in accordance with City Ordinance 90-15. It is further agreed that the City shall have the right to enter the above premises at reasonable times to inspect the reclaimed water piping and fittings, to discontinue City utilities for nonpayment of service charges, for tampering with the service (includes meter and appurtenances), for cross-connection inspection with another service or water source, or for any other reason that may be detrimental to the City system.
    I have read and understand the City’s Policies and Procedures for Reclaimed Water Service and agree to restrict use of reclaimed water for the purpose(s) described in this application. I understand that due to the chemical composition of reclaimed water, that it may not be compatible for irrigation of certain susceptible vegetation, and I agree that the City will not be held liable for damages that may occur to vegetation or for damages which may occur due to uses of reclaimed water for purposes not included in this application or interruptions to service, and agree to defend and hold harmless the City from all claims and judgments arising there from against the City by any person.

    I have read and understand the City’s Policies and Procedures for Reclaimed Water Service and agree to restrict use of reclaimed water for the purpose(s) described in this application. I understand that due to the chemical composition of reclaimed water, that it may not be compatible for irrigation of certain susceptible vegetation, and I agree that the City will not be held liable for damages that may occur to vegetation or for damages which may occur due to uses of reclaimed water for purposes not included in this application or interruptions to service, and agree to defend and hold harmless the City from all claims and judgments arising there from against the City by any person.

35. Signature

    Person responsible for paying water bill

36. Date

38. Service type

    1. New Service
    2. Reconnection

39. Meter Size:

40. Date:
    Date:

42. Work Order No:

43. Permit No:

Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

* indicates a required field