[Tippecanoe County] Lead Service Line Replacement Reporting Form

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Lead Service Line Replacement Reporting

Instructions: This form is to be completed by property owners who have replaced their portion of a lead service line. Please complete all fileds and attach all required documentation.

Property Owner Information

Property Owner Phone Number

Property Owner Email

Local Property Address

Preferred method of communication

Best time of day to contact

Please list any known hidden hazards or recent plumbing work on your property that may prevent the work or injure the workers such as buried sprinkler lines, underground electrical wiring, or previous excavation work.

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Contractor Information

Contractor Name

Contractor Phone Number

Please attach all construction-related documents associated with the service line replacement.

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Replacement Details

Date of Replacement

Material Used for Replacement

Copper

PVC

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City Replacement Commitment

Upon notification, the City of Lafayette will replace the City side of the service line, if replacement is required, within 45 days.

What to Expect:

Water Works will contact you approximately two weeks before the date of your City-side lead service line replacement.
Water Works will strive to leave your property as close to how it was found or better. This may involve:
- Temporary and permanent restoration of areas impacted by the work, including replacing brick, concrete, granite, or asphalt curbs, sidewalks, pavement, driveways, retaining walls, and overlay.
- Seeding, sodding, and plant replacement, where applicable.
- Scheduling permanent restoration at a different time if necessary.
Water Works will make efforts to avoid trees, shrubs, and living plants whenever possible.
Water Works will provide a six-month water filter to the property owner or residents, along with instructions for flushing faucets to remove any potential lead particles.
Water Works warrants the workmanship of the service line installation completed by the City of Lafayette for 12 months after completion, with liability limited to the cost of repairing or replacing the City side of the service line.

Electronic Signature Agreement

I hereby acknowledge and agree that checking this box constitutes my electronic signature. I understand that my electronic signature is legally binding and has the same effect as a physical signature under Indiana law.