Date of Application Submittal _________________________

Property Owner Names _____________________________________________________________

Address of Property _____________________________________________________________

Phone Numbers of Property Owners: Day _______________________ Evening __________________

Paid Real Estate Tax Receipt (Attached) __________________________________________________

Name of Plumbing Contractor that attempted to clean line _____________________________________

Name of Plumbing Contractor (if different from above) that performed dye testing or televising of line:


Phone Numbers for Plumbing Contractors(s) _______________________________________________

Is the Problem Area under a street or sidewalk? (Circle One) Yes No Uncertain

Has MSD or St. Louis County Health Department been contacted? (Circle One) Yes No Uncertain

Has the problem area been cabled, dye tested and/or televised? (Circle One) Yes No Uncertain

Has the entire line been scoped upon completion of repair?  (Circle One)  Yes  No  Uncertain

Attach a copy of certification from your plumbing contractor that an attempt was made to cable the line but that procedure failed to solve the problem. Indicate date, time and precise location of where on the service line the procedure took place.

Attach a copy of the release authorizing contractors to work on site, recognizing that noise, mud, dust, and other inconveniences may be part of the work and that landscaping, bushes, walks, fences, driveways and other minor items in the way of the work could be damaged and holding the City of Clarkson Valley harmless for such actions done by the contractor. Note: The property owner must complete final site restoration (such as landscaping).

________________________________________ _______________________________________
Property Owner Signature(s)


City Use Only:

Plumber Verification Form received

Subdivision Trustee's Advised

Affidavit on Completed Work and the associated paperwork received

  1. A written statement that the work has been completed; ___________________________
  2. Copies of the three (3) bids received; ____________________________
  3. The itemized bill from the contractor.___________________________

City Hall telephones St. Louis County - Plumbing Inspection Office 314-615-3723 or 314-615-0330 to request the inspection results. Faxed form letter received

Payment check issued and mailed

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