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2. Water & Sewer Adjustment Request

4. Account Number:*
6. Name*
8. Phone Number*
9. Email Address*
11. Service Address:*
13. Mark One:*

    1. Owner
    2. Tenant
    3. Landlord
15. Cause of Leak*
17. Water Service Line Material Where it Enters Your House*

    1. Plastic
    2. Copper
    3. Galvanized
    4. Ductile Iron
    5. Other
    6. Don't Know
19. Date Leak Found*
    Date Leak Found
20. Date Leak Repaired*
    Date Leak Repaired
22. • Please attach a copy of repair invoices or receipts
    • Please attach a letter of explanation if repairs made by yourself, with receipts, etc.
25. Sod Credit*

    1. Yes
    2. No

26. Sod Credit:  Issued for new construction homes

28. Pool Fill*

    1. Yes
    2. No

29. Pool Fill:  Provide size of pool, approximate gallons of fill, days of fill

30. Size of Pool, Approximate Gallons, Days of Fill
32. Acknowlegement*

    1. I acknowledge the information given above is true and correct to the best of my knowledge.

34. Please note that you will always be responsible for paying your monthly bill, late fees are not adjusted.

Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit Submit and Print

* indicates a required field