EmailMeForm
Water Pipe Survey - Customer
Service Address #
*
Service Address Street
*
Service Address Subdivision
*
Service Address Zip Code
*
63366
63376
Name of the Person Filling Out the Form
*
First
Last
Are you a:
*
Please select
Owner
Tenant/Renter
Property Manager
Other
Other
Is this a:
*
Please select
Single Family
Multi Family
School/Childcare
Business
Hospital/Medical Care Facility
Nursing Home
Other
Other
Year (range) Structure Plumbing Material was Installed
*
Please select
Before 1931
Between 1931 and 1978
Between 1978 amd 1986
After 1986
Actual Year Known
Unknown
Year
Service Line Material at the Point of Entry (inlet) to Your Home?
*
Lead
Copper
Galvanized
Other (Plastic/PVC/Plex)
Cannot Fiind Entry Point
Would like Assitance from Water District (provide phone or email below)
Pipe Material - Scratch Color - Does Magnet Stick?
Lead - Shiny Silver - No
Copper - Orange (penny) - No
Galvanized - (Dull Gray) - Yes
Plastic - NA - No
Has the line from the water meter to the home/building been replaced?
*
Please select
Yes
No
Unknown
Year
Material Type Used
Would you like to upload a photo of the water line inside the building or any other documents relating to the water line?
Add File
Phone
###
-
###
-
####
Please leave a phone number or email so that we can contact you about an inspection (if needed)
Email
Date Time
*
MM
/
DD
/
YYYY
Additional Comments (if needed)
