2. 

3. CITY OF ELLISVILLE

   1 Wies Avenue

   Ellisville, Missouri 63011

   Phone: 636.227.9660  *  636.227.9486

   
   

   AUTHORIZATION FORM

   SANITARY SEWER LATERAL REPAIR PROGRAM

5. Property Owner(s) Name:*
7. Owner(s) address (if different from property):
9. Property Address:*
11. Property City:*
12. State:*
13. Zip:*
15. Home Phone#: *
17. Work Phone#:
19. Cell Phone#: *
20. Email Address:*

22. PLEASE READ EACH ITEM, INITIAL, AND SIGN THIS FORM BELOW.

24. Request for assistance:*

    I, (please sign name above), do request the City of Ellisville initiate proceedings to investigate and resolve the subject problem under the rules promulgated for the City of Ellisville's Sewer Lateral Repair Program, described below.

26. 1. I understand the City or agents have the right to investigate the site prior to preparing any technical specifications.*
28. 2. I understand the City's sewer lateral insurance program covers only from the public sewer main to the outside wall of my home, and therefore, will not cover the cost of repairs within my home, and the City's investigation will not go beyond the covered area.*
30. 3. Prior to any encumbrance of the City's sewer lateral insurance fund, I agree to privately arrange for, and pay at my own expense, the costs associated with cabling the entire length of my sewer lateral line, as this could potentially solve the problem, and I will provide the City with a copy of the paid plumber's receipt. (Note: If the City must indeed make a repair, the private cabling cost will be reimbursed to the resident as part of the repair service. Max reimbursement amount is $250.00)*
32. 4. I understand that should the initial cabling and televising authorized by me, determine my sewer lateral does not have any damage covered by the sewer lateral program, as determined by the City of Ellisville, I will be responsible for reimbursing the City of Ellisville for all third party costs incurred by the City while investigating my request for service.*
34. 5. I understand that roots coming through a joint in the pipe are considered a maintenance issue, and will not be covered by this program. Only if the pipe is physically broken, collapsed, or offset, as determined by the City of Ellisville, will the sewer lateral program be available to me.*
36. 6. If, after cabling, it is determined that action by the City may be warranted under the repair program, I authorize the City to televise the cable my sewer lateral line to be determine the exact location(s) of the breach(es) for the purpose of defining the scope of work. I understand a copy of the paid cabling bill must be provided to the City with an explanation of why the line could not be opened prior to the City taking any action. I acknowledge that if these subsequent efforts indicate that the problem be deemed ineligible for funding under the City's program, I am responsible for reimbursing the City for these costs, since I would have to pay them anyway to diagnose the problem.*
38. 7. The homeowner will be provided a list of City-approved contractors. I understand that I am responsible for obtaining three (3) bids from this list to have the sewer lateral repaired.*
40. 8. The City will contract for the necessary repairs. I hereby authorized the City of Ellisville, and its contractors, to enter onto my property in order to repair my sanitary sewer lateral. As part of this work, I realize that there will be noise, dirt, dust, mud, and/or some degree of inconvenience. In the process, a large hole will be excavated and earth mounded in my yard. I understand my property could become temporarily damaged by the use of large machinery and the stockpiling of materials. *
42. 9. I agree to hold the City, and its contractors, harmless from minor damages that could result from this work. I fully understand that any shrubs, flowers, and other landscape structures that are near the construction area will be my respobsiblity to remove (prior to construction) or replace. The City, and its contractors, will not be responsibile for irrigation lines or other concealed (buried) improvements that are not properly located. *
44. 10. I understand that the City, and its contractors, reserve the right to reroute or replace the entire sewer lateral line if deemed necessary to prevent reoccurring problems in the future. I further understand the City, and its contractors, are not compelled to replace the entire sewer line, if such action is not deemed necessary.*
46. 11. I understand that the post-construction restoration work may result in the settling of soils, and while the City, and its contractors, will attempt to compact the soil to prevent settling, I agree to hild the City, and its contractors, harmless, and assume all responsibility for further yard fill, which may be reauired or desired as a result of the repar work.*
48. 12. I understand that post-construction restoration work includes grading and seedling by the City, and its contractors, and I agree to hold the City, and its contractors, harmless if the replacement grass does not survive. In this, I assume responsibility for the critical importance of lawn care, and the necessity of maintaining the grounds once the City, and its contractors, have completed all restoration work.*
50. 13. I agree to hold the City harmless if utilities are damaged from excvation due to the repair of the sewer lateral line.*
52. Signature of Property Owner:*
54. Date:*
    Date:

56. *Only property owners on record may apply for the Sewer Lateral Program*

Leave This Blank:


58. 1. Receive an email copy of this form.
59. Email address

    This field is not part of the form submission.

60. Submit

* indicates a required field