Applicant is: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Select one: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Landlord authorization

If applicant is a tenant, please provide the owner/landlord's contact information. Under state law provisions, a fully executed Landlord Authorization Form must accompany your request in order to establish water and/or sewer in a tenant’s name. Download and complete the Landlord Authorization Form (PDF) and upload it below.

{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}
{ binding firstError.message }
{ binding firstError.message }
Service address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Primary applicant

Applicant name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Secondary applicant

Secondary applicant name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Mailing/forwarding address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

Regulations Governing Utility Service
The JCSA Regulations Governing Utility Service were written to promote good public utility and good business practice. The regulations reflect the obligation of the JCSA to its customers and the requirements that the customer must observe. These regulations govern the relations between the customer and the JCSA. The regulations have been approved and adopted by the JCSA Board of Directors. Amendments to the regulations may be made only by approval of the JCSA Board of Directors.

{ binding firstError.message }

Disclaimer
Personal information provided to James City County and/or the James City Service Authority (JCSA) in the form of email or electronic form is used solely to respond to your request, inquiry or transaction. James City County/JCSA does not sell or rent personal information to any third party organization. James City County/JCSA does not provide specific information about users or other personally identifiable data to unaffiliated third parties for their independent use, except if required to do so by the Virginia Freedom of Information Act (FOIA) or other law. As set forth in Section 2.2-3705.1(10) of the Code of Virginia, you may request that your electronic mail address be exempt from disclosure pursuant to a FOIA request. Should you wish for your electronic mail address to be exempt from disclosure pursuant to FOIA, please send an email to the County Webmaster.

Applicant is: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Select one: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Start date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Stop date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

Landlord authorization

If applicant is a tenant, please provide the owner/landlord's contact information. Under state law provisions, a fully executed Landlord Authorization Form must accompany your request in order to establish water and/or sewer in a tenant’s name. Download and complete the Landlord Authorization Form (PDF) and upload it below.

Upload landlord authorization form {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}
{ binding firstError.message }
{ binding firstError.message }
Service address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Home dialysis required {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

Primary applicant

Applicant name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Driver's license number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Alternate phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }
Add another person to this account {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

Secondary applicant

Secondary applicant name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Driver's license number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Alternate phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }
Mailing/forwarding address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

Regulations Governing Utility Service
The JCSA Regulations Governing Utility Service were written to promote good public utility and good business practice. The regulations reflect the obligation of the JCSA to its customers and the requirements that the customer must observe. These regulations govern the relations between the customer and the JCSA. The regulations have been approved and adopted by the JCSA Board of Directors. Amendments to the regulations may be made only by approval of the JCSA Board of Directors.

By checking the box and submitting this form the customer acknowledges that water and/or sewer service will be provided in accordance with the James City Service Authority’s Regulations Governing Utility Service, including any amendments adopted by the Board of Directors. The Regulations can be found above. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

Disclaimer
Personal information provided to James City County and/or the James City Service Authority (JCSA) in the form of email or electronic form is used solely to respond to your request, inquiry or transaction. James City County/JCSA does not sell or rent personal information to any third party organization. James City County/JCSA does not provide specific information about users or other personally identifiable data to unaffiliated third parties for their independent use, except if required to do so by the Virginia Freedom of Information Act (FOIA) or other law. As set forth in Section 2.2-3705.1(10) of the Code of Virginia, you may request that your electronic mail address be exempt from disclosure pursuant to a FOIA request. Should you wish for your electronic mail address to be exempt from disclosure pursuant to FOIA, please send an email to the County Webmaster.