Laserfiche WebLink
SAMPLE <br /> <br /> State of California <br />The Resources Agency <br />Department of Water Resources <br /> Office of Water Conservation <br /> <br />WATER .AGENCY. LEAK REPtYR REPORT <br /> <br />Contract No. <br /> <br />Agency <br />Location <br />Time of Repair <br /> <br />W.O. No. <br /> <br />Date <br />Map No. <br />Foreman <br /> <br />Description of damage for mains and services <br /> <br />~nat part was damaged? <br /> ]Pipe bar[ell [ ]Flange nuts, bolts, tie rods <br /> ]Joint [ ]Other (describe) <br /> ~Valve <br /> <br />In your opinion, ~at caused the d~anage? <br /> <br />Estimated age of leak in months <br /> <br />Type of Break <br />r ]Split <br />r ~Hole <br />[ ]Circumferential split <br />[ 7Broken coupling <br />~ ]Service pulled <br />C ]Cracked at corporation <br /> stop <br />r ]Gasket blown <br />r ]Crushed pipe <br />[ ]Cracked Bell <br />[ ]Other (describe) <br /> <br />Leak Location: <br />r ]Water [ ]Service Size[ ] Depth to <br />Main Lateral inches top of pipe <br /> <br />Pipe Material: <br />~ ]Galv. Iron [ ]Ductile Iron r ]Copper System <br />r ]~]ack Iron r ]Cast Iron [ ~P.V.C. Pressure <br />~ ]Steel ~ ]A.C.P. f ~Polybutylene <br /> <br /> LOCATION OF LEAK: <br />(circle number closest to leak:) <br /> I 0 1 <br /> 3 3 <br /> 6 <br /> <br />Exgmine broken edEe of cast or ductile iron pipe: <br />Original Min. thickness Deterioration <br />thickness of good grey is on: <br /> metal remaining r ]Outside <br />inches inches ~ ]Inside <br /> <br />Size of Leak <br />Measured GPM <br />Estimated GPH <br />Method used: <br /> <br />Is there evidence of previous leak or <br />repairs in sg.me Eeneral area? []Yes [!No <br /> <br />Number of previous leak <br />repair clamps present <br /> <br />Last repair date (if known) <br /> <br />Type of Soil: <br />[]Rocky ~n%andy <br /> <br />CTClay rlHard Pan <br />[].adobe []Loam <br /> <br />Existing Be]dinS: <br />fiGravel/Sand <br /> <br />rnNative Soil <br />rlPea Gr~vel <br /> <br />Tn your opinion, should pipe <br />be replaced <br />[1Yes []Db []Po not Know <br /> <br />7f yes, explain extent on <br />reverse side. <br /> <br />SAMPLE <br /> <br /> <br />