San Leandro, CA · Alameda County
Sanitary Sewer Lateral Repair Claim Intention Form
Property owners complete this form as an attachment to an encroachment permit for sanitary sewer lateral repair work in San Leandro.
What this form is
This form records whether the property owner believes sewer lateral repair work is related to damage caused by City facilities and whether they intend to seek reimbursement. It is an attachment to an encroachment permit, not a claim form. The owner provides the property location and contractor, selects one of two statements, and signs and dates the selected statement.
Who needs it
A property owner seeking an encroachment permit for sanitary sewer lateral repair work completes this form and selects one of the two statements.
How to submit it
The form identifies the Engineering & Transportation Department at Civic Center, 835 East 14th Street, San Leandro, CA 94577. It lists phone (510) 577-3428 and fax (510) 577-3294.
About notarization
This form is signed without a notary; it does not identify a notarized or sworn attachment, so the property owner simply signs and dates the selected statement.
How to submit this form
- 1
Download The Form
Download the Sanitary Sewer Lateral Repair Claim Intention Form.
- 2
Complete The Form
Enter the owner, location, and contractor information, then select one of the two statements.
- 3
Gather Any Required Video
If the repair uses trenchless methods and the owner selects the claim-intention statement, provide a video of the existing pipeline before work.
- 4
Sign And Date
The property owner signs, prints their name, and dates the selected statement.
- 5
Submit With The Permit
Use the form as an attachment to the encroachment permit and refer to the Engineering & Transportation Department contact details printed on it.
Frequently asked questions
- What is the Sanitary Sewer Lateral Repair Claim Intention Form?
- It is an attachment to an encroachment permit. The property owner selects a statement about whether the repair is related to City facility damage and whether they intend to seek reimbursement.
- Do I need a notary for the Sanitary Sewer Lateral Repair Claim Intention Form?
- No. The property owner signs and dates the selected statement; the form does not call for notarization or identify a sworn attachment.
- How do I submit the Sanitary Sewer Lateral Repair Claim Intention Form?
- The form identifies the Engineering & Transportation Department at Civic Center, 835 East 14th Street, San Leandro, CA 94577, and lists a fax number of (510) 577-3294.
- Is this form a claim for reimbursement?
- No. The form states that it is not a claim form. It records the property owner's intention regarding a possible claim for reimbursement.