Leak Adjustment Request Form


OFFICE USE ONLY

LEAK ADJUSTMENT GRANTED: Yes: ______     No: ______       APPLICATION NUMBER: _________

REASON: _______________________________________________________________________________

DATE OF NOTIFICATION TO CUSTOMER: ____________________________

ADDITIONAL INFO: ________________________________________________________________________________

_____________________________________________________________________________________________________

Taken By (Initials): ___________

Date Received: ____________________________


Please complete the following.

The last averaged water meter reads show a significant increase in your water usage that will result in an increase in your sewer charges and may result in unauthorized use fees. Commercial and Industrial users, with a designated irrigation meter, are billed on an averaged metered water usage over a 12 month period.  Metered users with no designated irrigation meter are billed using the averaged metered reads from the months of January, February, and December.

This Leak Adjustment Request Form is being submitted by the customer to request relief from an abnormally high sewer bill as a result of a leak on the customer’s side of the point of service. To submit a Leak Adjustment request complete the following information and attach the required documentation. Failure to provide all the required information and/or documentation will result in no Leak Adjustment.

Account Number:  Name on Account: 

Service Address:

Day Phone Number:  Type of Leak:
 

Date Leake Occured:  Date Leak Repaired: 

Brief Description of Leak:

Required Documentation:

  • Copy of Repair Invoice (if repaired professionally)
  • Copy of Repair Receipts (if repaired by self)
  • Copy of Water Utility provider meter readings showing reduced water consumption after repair
  • Sketch of exact location of leak
  • Photographs of leaking pipe (if available)
  • Plumber Affidavit  of Leak and Repair
  • You may submit your Leak Adjustment Request form and documentation by:

Mail to: 
Kootenai-Ponderay Sewer District
P.O. Box 562
Kootenai, Idaho  83840

Drop off:
Our office is located at 511 Whiskey Jack Road.

Fax:  208-265-5326

Leave this empty:

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Signature Certificate
Document name: Leak Adjustment Request Form
lock iconUnique Document ID: dee048ad3aba4c6d5858d5c466212f8e358a3031
Timestamp Audit
March 18, 2020 4:57 pm PSTLeak Adjustment Request Form Uploaded by Colleen Johnson - [email protected] IP 38.146.75.102
March 19, 2020 8:33 am PSTLaura Dallas - [email protected] added by Colleen Johnson - [email protected] as a CC'd Recipient Ip: 38.146.75.102
April 3, 2020 9:43 am PSTLaura Dallas - [email protected] added by Colleen Johnson - [email protected] as a CC'd Recipient Ip: 38.146.75.102
April 3, 2020 9:44 am PSTLaura Dallas - [email protected] added by Colleen Johnson - [email protected] as a CC'd Recipient Ip: 38.146.75.102
April 3, 2020 9:45 am PSTLaura Dallas - [email protected] added by Colleen Johnson - [email protected] as a CC'd Recipient Ip: 38.146.75.102
April 3, 2020 9:46 am PSTLaura Dallas - [email protected] added by Colleen Johnson - [email protected] as a CC'd Recipient Ip: 38.146.75.102
April 3, 2020 9:48 am PSTLaura Dallas - [email protected] added by Colleen Johnson - [email protected] as a CC'd Recipient Ip: 38.146.75.102
April 3, 2020 9:49 am PSTLaura Dallas - [email protected] added by Colleen Johnson - [email protected] as a CC'd Recipient Ip: 38.146.75.102
April 3, 2020 9:51 am PSTLaura Dallas - [email protected] added by Colleen Johnson - [email protected] as a CC'd Recipient Ip: 38.146.75.102
April 3, 2020 9:52 am PSTLaura Dallas - [email protected] added by Colleen Johnson - [email protected] as a CC'd Recipient Ip: 38.146.75.102