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Please complete the following to sign up for Water/Wastewater services through the City of York.

All water / wastewater sign-ups must be completed & $75 deposit paid at least 24hrs in advance of desired service start date. Weekends & holidays excluded. Deposit needs to be paid the same day form is submitted, if it is submitted after regular business hours, it will need to be paid the next business day.

Bank Draft Form (PDF)

New Customer Information Información para nuevos clientes

Service to be connected*

Name/Business Name*

Property Address*

Own Rent

Mailing Address*

Main Contact*

Phone*

Emergency Contact*

Phone*

Employer

Phone

Spouse/Roommate

Phone

Relative/Friend

Phone

Signed (Applicant - Typing your full name constitutes a signature)*

Date*

Property Owner

Name*

Phone*

Will this property be used as a rental? Yes No

When signing up for water/wastewater service you are agreeing to comply with all State and/or City requirements and guidelines. Obtaining this information may include testing, surveys and/or forms to be completed and returned within a specific timeframe. Backflow testing and surveys are required by law, failure to comply with City and State requirements within the given timeframe can result in service being terminated.

(Optional)
Third Party Notification Form

In accordance with Legislative Bill LB-143 (1979) any residential subscriber who wishes to designate a third party to receive notification of any proposed discontinuance of services shall supply the Department of Public Works of the City of York, Nebraska (Water-Wastewater) with the following information.

1. Name of Third Party

Address of Third Party

Phone of Third Party

2. Notify Residents Only? Yes No

Signature of Subscriber (Typing your full name constitutes a signature)

File:

Image of Voided Check (if requesting bank withdrawals)

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