Sewer User Fee Adjustment for Water Leaks Application Form
Completed Town application form submitted by Tim and Cecilia Walzak regarding a broken water pipe at their property.
Town of View Royal Sewer User Fee Adjustment for Water Leaks Application Form
APPLICANTS NAME: Tim / Cecilia Walzak ACCT NO.: MAILING ADDRESS: 2203 Meadow Vale Dr. POSTAL CODE: V9B 6J2 PROPERTY ADDRESS: if different: TELEPHONE: CELL: FAX: — EMAIL:
Cause of leak: broken water pipe Date leak discovered: Aug. 18, 2013 Date repaired: Aug. 19th / 2013 Repairs done by: Tim Walzak (engineer), Tony Manuel (plumber)
- Receipts attached, OR
- Copy of CRD Water bill showing a leak adjustment for consumption period
PLEASE NOTE: YOUR ACCOUNT WILL BE REVIEWED. IF AN ADJUSTMENT IS WARRANTED IT WILL BE CALCULATED BELOW AND REDUCED BY A $25.00 ADMINISTRATION FEE.
DATE: Nov. 18/13
Personal information collected on this form is collected for the purpose of processing this application and for administration and verification. The personal information is collected under the authority of the Local Government Act and TOVR bylaws. If you have any questions about this collection, contact the Town by phone 250-479-6800, or Town Hall at 45 View Royal Avenue. Personal information or business information submitted on this form is not considered to be supplied in confidence.
This section is for TOVR use only
Type of Leak:
- * Non-Sewer Affected Leak
- * Sewer Affected Leak
Original Sewer Bill Amount:
| Description | Amount |
|---|---|
| Administration Fee | $ 25.00 |
| Customer’s 3 Year Historical Average Consumption (average m3) | $ (average m3 at current year $/m3) |
| Amount of Amended Sewer User Fee | $ |
| Adjustment or Refund to be applied to account | $ |
Refund / Invoicing Approved by: (Director of Finance) Date:
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