Affidavit Of Plumbing Testing
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1Affidavit of Plumbing Testing
With the inspector’s permission, per SPS 382.21(1)(b)1b, complete entire form. Use of this form is not
mandatory. The is a suggested format that a plumber may replace with their own affidavit. Print or type
clearly. Call for your rough inspection and inform the inspector that you have completed the testing and the
affidavit. Provide this completed form to the inspector prior to or at the time of the rough-in inspection.
Date of test:
type date
Responsible Master:
type your name
Responsible MP Number:
Enter your number
Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m)].
Owner and Site Information
Owner’s Name:
type owner 1 last name
Project Site Address:
type owner 1 street or PO box #
Project Site City:
type owner 1 city
Type of project (check one):
New plumbing installation
Remodel or addition
Repair
Other
If other, explain:
_________________________________________________________________
______________________________________________________________________________
Testing Information
Sanitary Building Sewer or Private
Water test (10’ for 15 minutes)
Interceptor Main Sewer:
Air test (3 psig for 15 minutes)
(air test not recommended for plastic pipe)
Water Service or Private Water Main::
Water test (Working pressure)
Air test (Working pressure)
Building Drain
Water test (10’ except for top 10’ for 15 minutes)
Air test (5 psig for 15 minutes)
Drain & Vent System
Water test (10’ for 15 minutes)
Air test (5 psig for 15 minutes)
Water Distribution
Water test (Working pressure)
Air test (Working pressure)
Air Admittance Valves
Manometer test to 1” water column
____________________________________
___________________________________
Responsible Master Plumber - signature
Witness (not required) - signature
SBD-10605(R11/11)
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