Sba - Private Sewer Lateral Repair Report Page 2

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Required enclosures:
1. Repair Authorization
2. DVD video inspection and re-inspection following repairs if needed
3. Complete Inspection Log. Note any observations using the observation codes
4. Sketch of lateral, lot, and building with dimensions referenced to front curb or edge of
pavement and side property lines where possible. If inspection is a long lateral note
spacing of cleanouts and entry locations for insertion of camera.
OBSERVATION CODES
B
BROKEN
I
INFILTRATION
R
ROOTS: 25% 50% 75%
C
CRACK
O
OFFSET
CP
CHANGE IN PIPE MATERIAL
F
FRACTURE
S
SAG
OR
OUT OF ROUND
LATERAL INSPECTION LOG
CODE
DISTANCE
OBSERVATION
*Sewer Lateral Video MUST be from House to Trap AND Trap to Main*
Site Sketch
J/SBA/Forms/SewerLateralInspectionsRepairForm2016
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J:\SBA\Forms\Sewer Lateral Inspection REPAIR Form 2016

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