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2. Date*
   Date
3. Contractor*
5. Business Address*
7. City*
8. State*
9. Zip Code*
11. Business Telephone*
12. Email Address*
14. Please select the appropriate box.*

    1. Water

    1. Sewer
16. Please select the appropriate circle.*

    1. Residential

    1. Business

    1. Multifamily

    1. Other
18. If other, please specify.
20. If commercial, please indicate meter size.
22. Tax Map Number
23. Lot Number*
25. Section/Phase
27. Subdivision*
28. Street Name*
30. Unit Description
31. Number of Bathrooms*
33. Number of Bathroom Fixtures*
35. If sewer, is a grinder pump required?

    1. Yes

    1. No
37. Note: A permit to make this water/sewer connection shall be obtained by your plumber from the James City County Building Safety and Permits Division.
Leave This Blank:


39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit

* indicates a required field