Form Center

2. You can print this form and submit to Snohomish City Hall with supporting documents or submit online and upload supporting documents.
4. First Name*
5. Last Name*
7. Service Address (98290 zip code only)*
9. Account Number
11. Phone Number*
12. Email
14. As a result of a leak, I received a water and sewer bill substantially higher than my normal consumption for the billing period of*
    As a result of a leak, I received a water and sewer bill substantially higher than my normal consumption for the billing period of Start Date

    —

    As a result of a leak, I received a water and sewer bill substantially higher than my normal consumption for the billing period of End Date
16. Date Leak was Fixed*
    Date Leak was Fixed
18. Description of repairs:*
20. The credit for water and sewer charges is based (hundreds of cubic feet) from high billing period, minus overage consumption units from last year, an adjusted overage water rate of $2.45, and an adjusted sewer rate of $4.68 (for 5/8" meters inside City limits). A Sewer Winter Average may also be taken into account based on the time of year.
22. I am the owner of the service address property and I am requesting that my bill be adjusted to a consumption level equal to the same billing period from the previous year. The attached copy of an invoice/receipt from a plumber or hardware store documents that the leak has been repaired. I understand I cannot receive another leak adjustment for this property for 24 months.
24. Attach a copy of an invoice/receipt from a plumber or hardware store, proving that the leak has been repaired.*
26. By submitting this application and entering my name below, I agree and acknowledge my electronic signature is valid and binding and contains the same force and effect as my handwritten signature. I acknowledge that the information submitted is true and correct and that I have authority, as the property owner, to and I am authorized to submit and execute this application for an Adjustment Due to a Water Leak. By submitting this application for an Adjustment Due to a Water Leak, I acknowledge that the application for an Adjustment Due to a Water Leak is subject to suspension or revocation if false or misleading information is provided; and violation of any conditions and/or requirements of the Snohomish Municipal code or any permit conditions may result in the revocation of an Adjustment Due to a Water Leak and the forfeiture of any fee paid.
28. Sign here*
29. Date*
    Date
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit Submit and Print

* indicates a required field