Merced County, CA · Merced County
Community Services Connections Request: Provider Form
Municipal or special district service providers complete this form to report water and sewer service requirements and availability for a parcel to Merced County Environmental Health.
At a glance
- Issued by
- City of Merced County · Merced County, Merced County, California
- Notarization
- Not required: file this form without a notary.
- Official source
- countyofmerced.com
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
A municipality or special district provider uses this form to report whether community water or sewer service is required or available for a parcel. Merced County Environmental Health requests it for certain projects, including those in a community or city service district, and it is valid for one year unless resubmitted within 365 days. The form asks for parcel, owner, provider, service, and representative details, plus service determinations and applicable septic-system questions.
Who needs it
A municipality or special district community services provider completes and submits this form when requested by Merced County Environmental Health for a parcel.
How to submit it
Submit the completed form to Merced County Division of Environmental Health, 2222 M St., Merced, CA 95340, or email it to [email protected] for review.
About notarization
The provider representative signs and dates this form without a notary; the document identifies no notarized or sworn attachment.
How to submit this form
- 1
Download the Form
Download the Community Services Connections Request: Provider Form.
- 2
Complete the Provider Details
Enter the parcel, property owner, service provider, district, and representative information, then answer the applicable water and sewer questions.
- 3
Gather Any Applicable Letter
If the provider agrees to specified septic-system work, the document says the provider must submit a letter on company letterhead.
- 4
Sign and Date
The provider representative affirms the information is correct by signing and dating the form.
- 5
Submit to the County
Send the completed form to Merced County Environmental Health by mail at the listed address or by email.
Frequently asked questions
- Do I need a notary for the Community Services Connections Request?
- No. The provider representative signs and dates the form without a notary. The document identifies no notarized or sworn attachment.
- How do I submit the provider form?
- Send it to Merced County Division of Environmental Health at 2222 M St., Merced, CA 95340, or email it to [email protected] for review.
- Who completes this form?
- A municipality or special district community services provider completes it to report water and sewer service requirements and availability for the parcel.
- How long is the request form valid?
- The document states that the request form is valid for one year unless it is submitted again within 365 days of completion.