Water Utility Service Agreement

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*This form must be completed by the water district that supplies water to the establishment.

*(Esta aplicacion necesita ser lleneda por el distrito de servicios que le proporciona el agua.)

*This form must be returned to the Environmental Public Health Division of Harris County Public Health & Environmental Services before a preopening inspection can be done.

*(Esta aplicacion necesita ser regresada al Deptartamento de Salud de Harris County Environmental Section antes de que se haga la inspecion para abrir su establesamiento.)

Name of Establishment

_______________________________________________________

Street Address

_________________________________________________________

Water and wastewater service will be provided to the above establishment by
(NAME OF UTILITY DISTRICT)

___________________________________________________________

Name of Utility Official

__________________________________________________________

Signature

__________________________________________________________

Title

_________________________________________________________

Date _____________________