Sba - Private Sewer Lateral Repair Report
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2SBA - PRIVATE SEWER LATERAL REPAIR REPORT
ANY REPAIR REQUIRES A PERMIT FROM THE BOROUGH @ 610-287-7442
Customer Name:
Email:
Phone:
Address:
Company Name:
Inspector's Name:
Phone:
Sewage Usage:
Pipe Size:
Pipe Material:
Residential / Commercial / Condo / Apt
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CCTV Date: _______________
Time: ________
Camera Direction: With Flow Against Flow Total Length: ___________
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Cleanout is accessible outside of building
There is a sewer ejector pump at this property
Private sewer lateral crosses neighboring private property
Private sewer lateral connects to Authority's sewer in public right of way
There is more than one structure at this address served by the private sewer lateral.
Property has been verified as having no outside surface drains (rainwater runoff) connected to
the sewer system
I recommend the following repairs to restore normal lateral function:
(PLEASE NOTE: ANY REPAIR REQUIRES A PERMIT FROM THE SCHWENKSVILLE BOROUGH @ 610-287-7442)
Master Plumber Signature:________________________________
Date:___________________
License #________________
Recommended repairs have been made (enclose a copy of the repair authorization,
contract, or invoices signed by the property owner)
Lateral has been re-inspected to verify repairs
I certify that the information, recommended repairs and video recording I have provided
with this form are true and correct:
Borough Plumbing Permit # ____________________________
The Information submitted herewith complies with all requirements set forth by the Borough of Schwenksville Code inclusive. I
declare under penalty of perjury that all information submitted here applies to the listed address only:
*Sewer Lateral Video MUST be from House to Trap AND Trap to Main*
Authority Representative Signature:________________________________
Date:___________________
Approve / Deny
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J/SBA/Forms/SewerLateralInspectionsRepairForm2016
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J:\SBA\Forms\Sewer Lateral Inspection REPAIR Form 2016
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