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10 day termination notice

Customer Name:






10-Day Notification


Date of Notice:


Date of Impending Disconnection:


Service Address to be Disconnected:


Amount of Delinquency:


Late Charge:


Current Balance:


Total Outstanding Balance:


Interest Rate to be Applied:                  10%



Water service to                                                                  is scheduled to be disconnected on

                       for non-payment.  To avoid the loss of water service, you must do one of the following:


(a)        pay the delinquent amount [including late fees] in full by 2:00 p.m. on the date of disconnection stated above; or

(b)       make an alternative payment arrangement as described below.


To avoid disconnection, payments can be made by online at, by mail, or in person. The District accepts checks, money orders and cashier’s checks. Credit card payments may be made online. Please do not mail cash or place cash in the payment drop box. Payment for delinquent service bills will not be accepted by field personnel at the time of disconnection.

If District staff is dispatched to disconnect service for non-payment, a $50.00 fee will be added to the balance owed.  A fee of no more than $150.00 will be applied if reconnection of service is requested after normal operating hours. If you are a tenant who is not responsible for paying water bills and your landlord has failed to pay a bill, you can avoid a service termination by following the steps described below.

Requesting Extension or Alternative Payment Arrangement:

If you are responsible for the water service bill, you have the right to request alternative payment arrangements regarding the current account balance, which may be granted at the District’s discretion. Payment arrangements must be made with the District by 3:00 p.m. the day before the schedule disconnection date.

In certain circumstances involving an adverse health condition and financial inability, the customer may be entitled to an alternative payment arrangement if the customer is able to provide proof of meeting all three of the following requirements prior to shut-off date.

(1)       Health Conditions – you must provide certification from a primary care provider that discontinuation of water service would be life-threatening to, or would pose a serious threat to the health and safety of, any person who lives at the property receiving service;

(2)       Financial Inability – you must demonstrate you are financially unable to pay by:

(a)        presenting a document that shows that any member of your household is a current recipient of one of the following benefits: CalWORKs, CalFresh, general assistance, MediCal, SSI/State Supplementary Payment Program, or California Special Supplemental Nutrition Program for Women, Infants and Children; or

(b)       declaring that your household’s annual income is less than 200% of the federal poverty level; and

(3)       Alternative Payment Arrangements – you must be willing to enter into an amortization agreement, alternative payment schedule or a plan for deferred or reduced payment to repay all delinquent charges, at the District’s option.

Documentation must be submitted to the District office. To allow sufficient time for processing your request for an alternative payment arrangement, you should return all required documentation as soon as possible. Upon timely receipt of proof of qualification and after confirming that information, the District will promptly contact you to request any necessary additional information or to notify you of the alternative payment arrangement, and corresponding terms, for which you are selected to participate. Possible alternative payment arrangements, to be selected by the District in its discretion, include: (1) amortization of the unpaid balance; (2) alternative payment schedules; (3) partial or full reduction of unpaid balance; or (4) temporary deferral of payment. 

Tenant Occupants (applicable only to tenants):

To avoid the loss of water service as a non-responsible tenant, you must contact your landlord, property manager or property owner to work out any disputes over payment of the water bill.

As a tenant you have a right to become a District customer responsible for the account. However, if you do this you will become responsible for all future billings for the water used at this property. If you meet our requirements to become a new customer and agree to comply with our rules and regulations, which may include the payment of a deposit, water service will be continued without requiring you to pay the current outstanding balance. Please call a District customer service representative at 530-878-8096 to learn how to continue water service at your address, receive an estimated monthly cost of water service, and to speak to a customer service representative in person.

Bill Review and Appeal Process:

If no prior appeal or request for review of a bill has been made, you may request an appeal or review of the bill to which this notice relates if the you allege the bill to be in error.  Appeals and requests for review must be in writing and must include documentation supporting the appeal or reason for review.  All appeals or requests for review must be delivered to the District office within five days of the customer’s receipt of this notice.

Upon receipt of an appeal or request for review, the [Midway Heights County Water District’s General Manager or his or her designee will review the appeal and render a decision.  You may appeal the decision of the General Manager or his or her designee to the Board of Directors, in writing, within three business days of receipt the General Manager’s decision.  The decision of the Board of Directors is final and binding. 

In some circumstances, financial assistance may be available from federal, state, local, or private sources. You may wish to contact the Placer County Human Services at 530-889-7610 to determine whether financial assistance is available.

A hard copy of District’s Policy on Disconnection of Residential Water Service for Nonpayment (which includes the appeal procedures) is available upon request.  It is also available electronically at the District’s website, If you would like to make a payment, make payment arrangements, or obtain more information about any of the other matters in this notice, please call the District at 530-878-8096 or come to the District office at 16733 Placer Hills Road, Meadow Vista CA. 95722 to speak to a customer service representative.