Three Rivers Fire District
Water Department
PO Box 182
Three Rivers, MA 01080
413-283-9284
DOMESTIC WATER SERVICE APPLICATION
Applicant Name ________________________________ Date __________________
Address _______________________________________ Phone# ________________
Service Location ___________________________________________________________
Excavation Contractor _____________________________ Phone#_________________
Address ___________________________________________
Estimated Date of Street Excavation _______________ DIG SAFE #_________________
Applicant has read and will comply with the Three Rivers Water Department’s Specification
and Requirements for Domestic Service Connections:
Signature________________________________________________
**************************DO NOT WRITE BELOW******************************
(separate form for each service)
Service No. _______ Service Size ________ Meter Size ________ Dwelling Units__________
Meter No. ____________ Meter Reading __________ Date Service Opened ____________
Street Excavation Permit Issued - YES NO
Entry Fee $ __________
Materials $ __________
Labor $ __________
Bill Service Connection Charges To: _____________________________
Address: _____________________________
_____________________________
Bill Quarterly Water Charges To: _______________________________
Address: ________________________________
________________________________
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