Property Address (required) Subdivision Name Lot Number Occupancy Date (if applicable) Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year2003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030203120322033 Sewer Use (required) Residential Commercial Industrial Water Provided By (required) BCPSD City of Martinsburg Well Community System Applicant Information Is the applicant a previous customer? Yes No If so, when Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year2003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030203120322033 Applicant's Name (required) Applicant's Social Security Number (required) Applicant's Telephone Number (required) Applicant's Mailing Address (required) Applicant's Place of Employment Applicant's Place of Employment Telephone Number Applicant's Place of Employment Address Name of Spouse Spouse's Place of Employment Spouse's Place of Employment Address Spouse's Place of Employment Telephone Number Ownership (required) Rent Own Other Property Owner's Name Property Owner's Telephone Number Property Owner's Mailing Address Appropriate fees must be paid with this application. $125.00 security deposit* $350 service connection fee *In order for us to process your application it is necessary that the applicant provide payment in the amount of $125.00, supply a copy of the current driver's license and the applicant's social security number. Not providing a completed application with the items above will delay the process. Attach Drivers License (required) Files must be less than 2 MB.Allowed file types: gif jpg jpeg png. Applicant Signature The Applicant is responsible for all charges due on this account. I understand that this application is accepted subject to availability of service at this location. I have read the reverse and agree to take sewer service, to pay monthly invoices upon receipt, and to abide by all of the Berkeley County Public Service Sewer District's rules and regulations until discontinued by my request in writing. Leave this field blank