Manatee County Utilities

Temporary Backflow Device Request

Builder Company Name

Phone Number

# of Units

Subdivision

Phase #

Lot #

Permit #

Type of Service

Potable

Reclaimed

Please confirm the following:

Lot is clearly marked with a lot number or building permit is posted

Meter box and lid are visible and accessible

Meter resetter inside box is not bent or altered

Meter service has water

Requester's Signature

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.