Wastewater Usage Charges Adjustment Request Form

Utilities Commission, City of New Smyrna Beach, Florida

Phone (386) 427-1361 | Fax (386) 424-2713 | www.ucnsb.org 

To be completed and signed by customer
First Name:
Last Name:
Account Number:
Service Address:
*E-Mail:
City:
State:
Zip Code:
Phone#:
Please note: There is a $35 service fee for this request. UCNSB reserves the right to require additional documentation prior to consideration and is the final authority in the determination of adjustment requests. Limit of one adjustment per location per incident type (pool filling and new landscape only) each calendar year. Adjustments must be requested within 6 months of incident.
 
Only wastewater usage charges may be adjusted. No adjustment is made for new landscaping installation if customer has irrigation meter on premises. No adjustment is made for running toilets or leaking faucets. Usage pattern during the timeframe in which the incident occurred must be abnormally higher than average for an adjustment to be issued.
  Reason For Adjustment
Pool Filling:
DateFilled:
A letter from the pool company is acceptable or fill in the information below:
Gallons used:
Water Meter Readings:
Start
End
Pool Shape:
Rectangle:
Round:
Oval:
Other:
Pool Size:
Length:
Width:
Shallow End Depth:
Deep End Depth:
New Landscape:
Date Installed:
 
 
Attach receipt from landscaping company or garden center here.
Leak:
Date of Incident:
Date of Repair:
 
Location of leak in the home:
Attach copies of all of the following:
  • Plumber Invoice or Receipt for Materials
  • Pictures of Damage/Leak
Brief Description of Incident:
*All fields marked with a red asterisk are required
 
Applicant Signature
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