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2. Lakehaven Water and Sewer District
   31627 1st Avenue S
   P.O. Box 4249
   Federal Way, WA 98063-4249
   Federal Way: 253-941-1516
   Tacoma: 253-927-2922
   Fax: 253-839-9738
   www.lakehaven.org
3. Today’s Date
   Today’s Date
5. Name
6. Account Number
8. Address
10. City
11. State
12. Zip Code
14. Service Address
16. City
17. State
18. Zip Code
20. Home Phone Number
21. Cell Phone Number
22. Work Phone Number
23. Other Phone Number
25. Email Address
    Please provide your email address if you would like us to respond via email.
    
    (If you would like a copy of this form emailed to you, you must enter your email again in the submission section of this form.)
27. Date Leak Was Discovered
    Date Leak Was Discovered
28. Date Leak Was Repaired
    Date Leak Was Repaired
30. Description of leak:
32. Where was leak located?
34. Description of repair:
    Describe where the water leak was located and what steps you took to resolve the problem? e.g. "Toilet in master bath was leaking, replaced toilet."
36. Leak Adjustment Information
    If you are signed up for auto-pay please call Customer Service 253-941-1516 to avoid excess charges.
    
    Adjustment Calculations: 50% of the difference between the actual CCF (100 cubic feet) of water billed and the “averaged” CCF of water consumed during the same billing period of the previous year – not including the base rate.
    
    Adjustment Period:Maximum 3 billing cycles. One leak adjustment allowed every 2 years.
38. Return Your Request
    Return your request along with any receipts that support your entitlement to this leak adjustment via one of the following options:
    Mail
    Email
    Fax
    (This information can be found at the top of the form)
40. Signature*

    By checking the box below you agree that the information on this form is correct.

    1. I Agree
41. Date
    Date
43. Print Option
    For best printing results, check the box to "Receive email copy" and provide your email address.
    
    Look for an email with subject line of: "Online Form Submittal: Lakehaven Leak Adjustment Request Form". Ensure that your email program does not block email from "noreply@CivicPlus.com".
    
    Print the email from your email program.
Leave This Blank:


47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit

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