Date of Application Submittal _________________________
Property Owner Names _____________________________________________________________
Address of Property _____________________________________________________________
Phone Numbers of Property Owners: Day _______________________ Evening __________________
Paid Real Estate Tax Receipt (Attached) __________________________________________________
Name of Plumbing Contractor that attempted to clean line _____________________________________
Name of Plumbing Contractor (if different from above) that performed dye testing or televising of line:
____________________________________________________________________________________
Phone Numbers for Plumbing Contractors(s) _______________________________________________
Is the Problem Area under a street or sidewalk? (Circle One) Yes No Uncertain
Has MSD or St. Louis County Health Department been contacted? (Circle One) Yes No Uncertain
Has the problem area been cabled, dye tested and/or televised? (Circle One) Yes No Uncertain
Has the entire line been scoped upon completion of repair? (Circle One) Yes No Uncertain
Attach a copy of certification from your plumbing contractor that an attempt was made to cable the line but that procedure failed to solve the problem. Indicate date, time and precise location of where on the service line the procedure took place.
Attach a copy of the release authorizing contractors to work on site, recognizing that noise, mud, dust, and other inconveniences may be part of the work and that landscaping, bushes, walks, fences, driveways and other minor items in the way of the work could be damaged and holding the City of Clarkson Valley harmless for such actions done by the contractor. Note: The property owner must complete final site restoration (such as landscaping).
________________________________________ _______________________________________
Property Owner Signature(s)
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City Use Only:
Plumber Verification Form received
______________________________________________________
Date
Subdivision Trustee's Advised
__________________________________________________________
Date
Affidavit on Completed Work and the associated paperwork received
City Hall telephones St. Louis County - Plumbing Inspection Office 314-615-3723 or 314-615-0330 to request the inspection results. Faxed form letter received
_____________________________________
Date
Payment check issued and mailed
________________________________________________________
Date
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