Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Application for Acceptance of a Portion of a Private Water and/or Sewer Lateral for Maintenance by the Town

  1. Middleburg

  2. APPLICATION FOR ACCEPTANCE OF PORTION OF PRIVATE LATERAL BY TOWN

  3. Requested Action (check all that apply)

  4. I/We, the owner(s) of the above-listed property, do hereby request that the Town accept a portion of the private water/sewer lateral as indicated above, serving our property for repair and maintenance. In order to assess this request, a plat is attached that shows the following information as an attachment:*

  5. In consideration of the granting of this application, I/We covenant and agree to the following:*

  6. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  7. Leave This Blank:

  8. This field is not part of the form submission.