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2. 
3. Coachella Valley Water District
   Canal Water Service Request - Authorization of Agent (CVWD-106)
   
   
   
   
   
   
5. Meter Number*
7. Company Name*
9. Property Owner First Name*
10. Property Owner Last Name*
12. Property Owner Title*
13. Property Owner Email Address*
15. Property Owner Telephone Number*
16. Property Owner Telephone Number Type*

    1. Cell phone
    2. Work
    3. Home
18. Property Owner Mailing Address *
20. City*
21. State or Province*
22. Zip or Postal Code*
24. Is the billing information the same as above?*

    1. Yes
    2. No
26. Billing Company Name*
28. Billing First Name*
29. Billing Last Name*
31. Billing Title*
32. Billing Email Address*
34. Billing Telephone Number*
35. Billing Telephone Number Type*

    1. Cell phone
    2. Work
    3. Home
37. Billing Mailing Address*
39. City*
40. State or Province*
41. Zip or Postal Code*
43. Are you the new owner of the property?*

    1. Yes
    2. No
44. Will existing users stay on the account?*

    1. Yes
    2. No
46. List user names to remove from the account.
48. Will you be leasing the property?*

    1. Yes
    2. No
49. To whom will you be leasing the property?*
51. Is a well located on your property?*

    1. Yes
    2. No
52. State Well Number*
53. Active?*

    1. Yes
    2. No
54. Abandoned?*

    1. Yes
    2. No
56. Will you be multicropping?*

    1. Yes
    2. No
58. Water will be used for: (check all that apply)*

    1. Alfalfa
    2. Bell Peppers
    3. Carrots
    4. Citrus

    1. Dates
    2. Grapes
    3. Nursery - Trees
    4. Okra

    1. Oriental Vegetables
    2. Strawberries
    3. Construction

    1. Duck Farm
    2. Fish Farm
    3. Golf Courses / Lakes

    
    

    
    

    
    

    Note:  Industrial Hemp cannot be irrigated with Federal canal water at this time. Any applications for canal water service with Industrial Hemp as a crop will be denied until further notice.

60. Parcel Information*

    This Canal Water Service Request – Authorization of Agent form must list the parcel and all additional parcels served by the above meter. This will allow for the proper application of paid Canal water charges to each parcel to which water is actually being delivered.
    
    CREDIT WILL NOT BE GIVEN TO PARCELS NOT LISTED ON THIS FORM OR TO PARCELS TO WHICH WATER IS NOT ACTUALLY DELIVERED.
    
    

    1. I hereby apply for water service and certify that water is served by the above meter to the following parcels:
62. Parcel Number*
63. Number of Acres*
64. Section*
66. Township (S)*
67. Range (E)*
68. 1. Check here to add another parcel
70. Parcel Number*
71. Number of Acres*
72. Section*
74. Township (S)*
75. Range (E)*
76. 1. Check here to add another parcel
78. Parcel Number*
79. Number of Acres*
80. Section*
82. Township (S)*
83. Range (E)*
84. 1. Check here to add another parcel
86. Parcel Number*
87. Number of Acres*
88. Section*
90. Township (S)*
91. Range (E)*
92. 1. Check here to add another parcel
94. Parcel Number*
95. Number of Acres*
96. Section*
98. Township (S)*
99. Range (E)*
101. List additional parcels on a separate page or upload here.
103. Water Orders*

     1. I authorize the following individuals to order water through this meter
105. Property Owner First Name*
106. Property Owner Last Name*
107. Property Owner Cell Phone*
109. 1. Check here to add another individual
111. First Name*
112. Last Name*
113. Cell Phone*
115. 1. Check here to add another individual
117. First Name*
118. Last Name*
119. Cell Phone*
121. 1. Check here to add another individual
123. First Name*
124. Last Name*
125. Cell Phone*
127. 1. Check here to add another individual
129. First Name*
130. Last Name*
131. Cell Phone*
133. 1. Click here to add another individual
135. First Name*
136. Last Name*
137. Cell Phone*
139. List additional individuals on a separate page or upload here.
141. Terms & Conditions*

     1. I understand that the start date for service depends on verification by CVWD that the water lines are in proper working order.

     I hereby authorize the above named water user, if any, and his/her designees to sign or give orders to Coachella Valley Water District for the delivery of water through this meter. By signing this document, I certify I am the legal property owner for the parcels identified within this application; all information is true and correct. I assume all responsibility for any bills, costs, loss, damage, penalties, charges, or fees associated with this meter under the Regulations of the District. This authorization shall be revocable at any time upon written notice to the District. A $46 Account Establishment Fee will appear on my first bill. I acknowledge and agree to comply with all District Regulations, Ordinances, Policies and Rules, and amendments thereto. Where the demand for water exceeds the available water supply, water orders may be delayed except under emergency conditions as determined by the District. Service may be interrupted for the purpose of repair and maintenance at any given time.

143. By typing or signing my name, I certify that I understand the terms and conditions outlined above and that to the best of my knowledge the information I provided is true and correct.*
145. Property Owner Title*
146. Date Signed:*
148. CVWD Use Only
150. New Meter Sequence:
     
     
152. Additional User:
     
     
154. Refund Agreement Number:
     
     
156. Last Date Meter Used:
     
     
158. Lateral Remarks:
     
     
160. Notes:
     
     
162. Customer Service - Processed By & Date:
     
     
164. Customer Billing - Processed By & Date:
     
     
166. Zanjeros - Processed By & Date:
     
     
168. Customer Billing - Processed By & Date:
     
     

170. COACHELLA VALLEY WATER DISTRICT

     Post Office Box 1058

     Coachella, California 92236

     (760) 391-9600

     (760) 398-3190 - fax

     CustomerService@cvwd.org

     
     

     rev 10/2021

Leave This Blank:


171. 1. Receive an email copy of this form.
172. Email address

     This field is not part of the form submission.

173. Submit

* indicates a required field