{"id":5479,"date":"2021-11-24T17:12:04","date_gmt":"2021-11-24T17:12:04","guid":{"rendered":"https:\/\/bentonil.com\/?page_id=5479"},"modified":"2021-11-24T17:14:16","modified_gmt":"2021-11-24T17:14:16","slug":"application-for-new-water-sewer-service","status":"publish","type":"page","link":"https:\/\/bentonil.com\/?page_id=5479","title":{"rendered":"Application for New Water\/Sewer Service"},"content":{"rendered":"<div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f5476-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><\/div>\n<form action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F5479#wpcf7-f5476-o1\" method=\"post\" class=\"wpcf7-form\" novalidate=\"novalidate\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"5476\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.1.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f5476-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"g-recaptcha-response\" value=\"\" \/>\n<\/div>\n<link rel=\"stylesheet\" href=\"https:\/\/bentonil.com\/wp-content\/plugins\/pdf-forms-for-contact-form-7\/css\/frontend.css\" \/><script type=\"text\/javascript\" src=\"https:\/\/bentonil.com\/wp-content\/plugins\/pdf-forms-for-contact-form-7\/js\/frontend.js?ver=2.1.2\"><\/script><p>APPLICATION FOR INSTALLATION OF WATER\/SEWER NEW SERVICE<\/p>\n<p>Applicant:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<span class=\"wpcf7-form-control-wrap Applicant\"><input type=\"text\" name=\"Applicant\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\nDate of Birth:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<span class=\"wpcf7-form-control-wrap DOB\"><input type=\"date\" name=\"DOB\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\nPhone:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<span class=\"wpcf7-form-control-wrap telephone\"><input type=\"tel\" name=\"telephone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span>  <\/p>\n<p>Co-Applicant: &nbsp;&nbsp;&nbsp;<span class=\"wpcf7-form-control-wrap Co-applicant\"><input type=\"text\" name=\"Co-applicant\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><br \/>\nDate of Birth: &nbsp;&nbsp;&nbsp;<span class=\"wpcf7-form-control-wrap co-applicant-DOB\"><input type=\"date\" name=\"co-applicant-DOB\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/p>\n<p>Service Address: <span class=\"wpcf7-form-control-wrap address\"><input type=\"text\" name=\"address\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/p>\n<p>Drivers License#: <span class=\"wpcf7-form-control-wrap driverslicense\"><input type=\"text\" name=\"driverslicense\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\nLast 4 Digits of Social Security#: <span class=\"wpcf7-form-control-wrap social\"><input type=\"text\" name=\"social\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/p>\n<p>Has applicant(s) had service with City of Benton before?   <span class=\"wpcf7-form-control-wrap prev-service\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"prev-service\" value=\"YES\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">YES<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"prev-service\" value=\"NO\" \/><span class=\"wpcf7-list-item-label\">NO<\/span><\/span><\/span><\/span><br \/>\nIf yes, when:  <span class=\"wpcf7-form-control-wrap prev-serv-date\"><input type=\"date\" name=\"prev-serv-date\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/p>\n<p>Do you owe a previous bill with the city?   <span class=\"wpcf7-form-control-wrap prev-owe\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"prev-owe\" value=\"YES\" \/><span class=\"wpcf7-list-item-label\">YES<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"prev-owe\" value=\"NO\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">NO<\/span><\/span><\/span><\/span><br \/>\nIf yes, how much?  <span class=\"wpcf7-form-control-wrap amount-owed\"><input type=\"text\" name=\"amount-owed\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/p>\n<p>Is the property inside Benton city limits?  <span class=\"wpcf7-form-control-wrap in-city-limits\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"in-city-limits\" value=\"YES\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">YES<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"in-city-limits\" value=\"NO\" \/><span class=\"wpcf7-list-item-label\">NO<\/span><\/span><\/span><\/span> <\/p>\n<p>If outside city limits an ANNEXATION AGREEMENT (direct or 20 year) must be signed and approved before water service can be established.<\/p>\n<p>Is this a mobile home?  <span class=\"wpcf7-form-control-wrap is-mobile-home\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"is-mobile-home\" value=\"YES\" \/><span class=\"wpcf7-list-item-label\">YES<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"is-mobile-home\" value=\"NO\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">NO<\/span><\/span><\/span><\/span><\/p>\n<p>Rent or own?  <span class=\"wpcf7-form-control-wrap rent-or-own\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"rent-or-own\" value=\"Rent\" \/><span class=\"wpcf7-list-item-label\">Rent<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"rent-or-own\" value=\"Own\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Own<\/span><\/span><\/span><\/span><br \/>\nIf renting:<br \/>\nProperty owners name:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<span class=\"wpcf7-form-control-wrap rental-owners-name\"><input type=\"text\" name=\"rental-owners-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><br \/>\nProperty owners address:&nbsp;&nbsp;<span class=\"wpcf7-form-control-wrap rental-owners-address\"><input type=\"text\" name=\"rental-owners-address\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><br \/>\nProperty owners phone#:&nbsp;<span class=\"wpcf7-form-control-wrap rental-owner-phone\"><input type=\"tel\" name=\"rental-owner-phone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" aria-invalid=\"false\" \/><\/span><\/p>\n<p>Date service requested:  <span class=\"wpcf7-form-control-wrap req-serv-date\"><input type=\"date\" name=\"req-serv-date\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/p>\n<p>I, <span class=\"wpcf7-form-control-wrap responsible-name\"><input type=\"text\" name=\"responsible-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span>, will be responsible for paying all water and sewer bills that are incurred at the address for which I have requested service. If they are not paid as required, I understand that my water service may be discontinued and that I will be responsible for attorney fees, and any and all extra costs to recover the payment.<\/p>\n<p><span class=\"wpcf7-form-control-wrap obligation-ack\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"obligation-ack[]\" value=\"For renters there is a $150 deposit that must be paid in our office to connect water services. A copy of your deed\/lease must also be on file in our office. Please bring it with you when you pay your deposit. Check this box too confirm your obligation to comply.\" \/><span class=\"wpcf7-list-item-label\">For renters there is a $150 deposit that must be paid in our office to connect water services. A copy of your deed\/lease must also be on file in our office. Please bring it with you when you pay your deposit. Check this box too confirm your obligation to comply.<\/span><\/span><\/span><\/span><\/p>\n<p><input type=\"submit\" value=\"Submit Request\" class=\"wpcf7-form-control wpcf7-submit\" \/><\/p>\n<div class=\"wpcf7-response-output wpcf7-display-none\"><\/div><\/form><\/div>\n<!-- AddThis Advanced Settings generic via filter on the_content --><!-- AddThis Share Buttons generic via filter on the_content -->","protected":false},"excerpt":{"rendered":"<p><!-- AddThis Advanced Settings generic via filter on get_the_excerpt --><!-- AddThis Share Buttons generic via filter on get_the_excerpt --><\/p>\n","protected":false},"author":1,"featured_media":0,"parent":41,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"ngg_post_thumbnail":0,"_cbd_carousel_blocks":"[]","_mc_calendar":[]},"_links":{"self":[{"href":"https:\/\/bentonil.com\/index.php?rest_route=\/wp\/v2\/pages\/5479"}],"collection":[{"href":"https:\/\/bentonil.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/bentonil.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/bentonil.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/bentonil.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=5479"}],"version-history":[{"count":3,"href":"https:\/\/bentonil.com\/index.php?rest_route=\/wp\/v2\/pages\/5479\/revisions"}],"predecessor-version":[{"id":5483,"href":"https:\/\/bentonil.com\/index.php?rest_route=\/wp\/v2\/pages\/5479\/revisions\/5483"}],"up":[{"embeddable":true,"href":"https:\/\/bentonil.com\/index.php?rest_route=\/wp\/v2\/pages\/41"}],"wp:attachment":[{"href":"https:\/\/bentonil.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=5479"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}