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Leak Adjustment Request

2. This leak adjustment request must be filled out by the owner of the property. If you are a tenant, please contact the owner and ask them to fill out this form.

4. Please click on the following link to read City Resolution no. 655, which establishes a one-time water leak adjustment policy:
   City Resolution no. 655

6. Resolution no. 655*

   1. I have read and understand City Ordinance # 655 establishing a one-time water leak adjustment policy.

8. Notification of leak*

   1. I certify that the leak on the service address listed below was repaired within ten (10) days of notification or discovery of leak.

10. Notification of Leak *

    1. I certify that I have notified the city of the leak within a one month period of the discovery of the leak.

12. First Name*

13. Last Name*

15. Service Address*

17. City

18. State

19. Zip Code

21. Phone Number

22. Account Number

23. Date you were notified or became aware of leak*
    Date you were notified or became aware of leak

25. Date leak was repaired*
    Date leak was repaired

27. Supporting Documents*

    1. I understand that I must provide supporting documentation that the leak was fixed. If I do not provide documentation, I may not receive the leak adjustment.

29. Supporting Documents Upload

    Please attach any supporting documents and/or receipts that verify your leak has been repaired. If you cannot scan and upload them, please send to Tami Wood: Email: twood@ci.snoqualmie.wa.us; Mail: PO Box 987; Snoqualmie 98065; In Person at City Hall: 38624 SE River St; Snoqualmie 98065

31. Notes or explanation for Utility Clerk*

    Please explain how you have or will be submitting your supporting documents that the leak was fixed.

33. Signature*

    I am the owner of the above named property and the leak on the service address was repaired within ten (10) days of notification of leak. I have read and understand City Resolution no. 655 and certify that all the information contained herein is accurate, to the best of my knowledge.

35. Please provide an email address for questions about your request:*

37. If you have questions, please email Tami Wood: twood@ci.snoqualmie.wa.us

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

    This field is not part of the form submission.

42. Submit Submit and Print

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