Urban water systems (UWSs) are challenged by the sustainability perspective. Certain limitations of the sustainability of centralized UWSs and decentralized household level wastewater treatments can be overcome by managing UWSs at an intermediate scale, referred to as small to medium sized UWSs (SMUWSs). SMUWSs are different from large UWSs, mainly in terms of smaller infrastructure, data limitation, smaller service area, and institutional limitations. Moreover, sustainability assessment systems to evaluate the sustainability of an entire UWS are very limited and confined only to large UWSs. This research addressed the gap and has developed a set of 38 applied sustainability performance indicators (SPIs) by using fuzzy-Elimination and Choice Translating Reality (ELECTRE) I outranking method to assess the sustainability of SMUWSs. The developed set of SPIs can be applied to existing and new SMUWSs and also provides a flexibility to include additional SPIs in the future based on the same selection criteria.