2. SEWER LATERAL REPAIR PROGRAM (SLRP) AND WATER SERVICE REPAIR PROGRAM (WSRP) APPLICATION

4. Service Address*
5. Utility Account #
7. Property Owner Name *
9. Property Owner Address *
11. Property Owner Phone Number*
13. Property Owner Email Address*
15. TYPE OF SERVICE (check all that apply):
17. I understand that if I am enrolling in the Sewer Lateral Repair Program (SLRP) and/or the Water Service Repair Program (WSRP) for the property described above that I hereby certify that I am the owner or contract purchaser of the property; the water services for the property is free from leaks and in working order and/or the sewer lateral for the subject property is in working order.*

    1. Please sign me up for the Sewer Lateral Repair Program (SLRP) for $27 per quarter. I have read, understand and accept the agreement.
    2. Please sign me up for the Water Service Repair Program (WSRP) for $15 per quarter. I have read, understand and accept the agreement.
19. Account will be billed quarterly beginning the first utility bill after service starts.
21. I understand that the charges for the services requested in this application will be added to the property owner's utility bill once the application has been processed. Charges will continue to be billed until such time the property is sold or a request for cancellation of voluntary services has been submitted to the City of Rock Island. Failure to pay any of the fees associated with these programs could result in immediate termination of the voluntary service.*

    1. Yes
    2. No
Leave This Blank:


23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit Submit and Print

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