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2. Name
3. Date
   Date
5. Address
7. Phone
9. Residential or Commercial

   1. Residential
   2. Commercial
11. I, undersigned have read and will comply with both the City of Lynn Haven and the Florida Department of Environmental Protection policies, procedures, and regulations for Reclaimed Water Service, and agree to use reclaimed water for the purposes described there in. For more information, the following websites are available.
13. Ordinances
    COLH Ordinances, Chapter 70, Article VI
15. Rules
    Florida Department of Environmental Protection Rules
17. Upon transfer of owner or resident, I will inform the new owner or tenants that the property is connected to reclaimed water.
    
    I further agree that the City of Lynn Haven Utility Department shall have the right to inspect the reclaimed water piping connections. The City has the right to discontinue the reclaimed water service for tampering with the system, cross connecting with another service or water source, or for any other reason that may be detrimental to the City of Lynn Haven.
    
    A monthly Fee for the availability of reclaimed water will apply.
    
    I hereby accept the terms as stated.
19. Print Name
20. Date
    Date
22. Electronic Signature Agreement

    1. I agree

    By checking the "I agree" box, you agree and acknowledge that your application will not be signed in the sense of a traditional paper document, 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 you may still be required to provide a traditional signature at a later date.
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