Application for Water & Server Service

City Hall
P.O. Box 1819
Buellton, CA 93427
T: (805) 688-5177
F: (805) 686-0086
City Hall Hours: 8:00 a.m. to 5:00 p.m. Monday through Friday

Please complete the form below. A downloadable from is also available here.

*Required Fields

*Service Type:

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*Service Address:

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*Effective Date:

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*Name:

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Spouse's Name:

*Home Phone:

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Business Phone:

*Email:

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Emergency Contact:

Phone:

*Mailing Address:

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*City:

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*Do you own or rent?

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If renting, please provide the following information.
Owners Name
Address
Phone
Email

*Driver's License Number:	Required	*Exp: Required
Spouse's Driver's License Number:		Exp:
*Social Security Number:	Required	*DOB: Required
Spouse's Social Security Number:		Spouse DOB:

Employed By
Employer Address

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