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2. Request for Underground Leak Adjustment

   1. The Department reserves the right to deny adjustment requests.

   2. Department recommendations are FINAL

   3. Leaking fixtures such as toilets, faucets, burst hoses, etc., will not be considered for an underground adjustment.

   4. Adjustments are not considered without plumber’s certificate, information, and/or receipts

   5. Adjustments will range from 0-35%, if proof of entire water line replacement is provided customers may qualify for additional adjustments.

   6. One adjustment per 2-year period

   7. Adjustments are considered for burst underground water lines only.

   8. Adjustments will only be considered for bills that have increased by at least 100% of a 12 month average.

   9. The highest bill will be adjusted if leak occurred within more than one billing cycle.

4. Section 1 - Customer's Statement
6. Name on Account*
7. Email Address
9. Service Address*
11. Account #
12. Amount of Bill *
13. Telephone Number (During our Office Hours)*
15. Reason for excessive use:*
17. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your request will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date (4) the above entered information is true.

    1. I agree.
19. Electronic Signature*
20. Date*
    Date
24. Section 2 - Plumber's Affidavit/Certification

    Adjustments are not considered without having either a signed Plumber's Affidavit or attached bill.

26. Name of plumbing company or individual doing repair work*
27. Date Repair was Made*
29. Description of Repair Made *
31. Were Repairs due to Underground Leak?*

    1. Yes
    2. No
32. Phone Number
33. Date*
    Date
35. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date (4) above statements are true.

    1. I agree.
37. Electronic Signature of Plumbing Company

    An uploaded copy of the plumber's bill may be submitted in lieu of the Plumber's affidavit.

38. Plumbing Bill/Receipts
Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

* indicates a required field