Private Sewer Lateral Video Inspection

Sewer Lateral Video Requirements:

Image is clear.
Property address or visual reference of property is shown.
Date and time of video are displayed.
Running foot or time marker is displayed.
Brief stops at each joint to show integrity.
Drain end and sewer lateral start are identified.

Acknowledgement and Confirmation the above Sewer Lateral Video Requirements have been met. *

I acknowledge and confirm all the above Sewer Lateral Video Requirements have been met.

Inspection Submission Requirements:

Attach a sketched plan with this application depicting the sewer main, street, building, lateral location, and trees located within 20 feet of the PSL.
Upload the video to pinellas.gov/access-portal.
If roots obstruct camera travel, provide videos of both before and after roots are cut and removed.
If there is a sag or "belly" identified, the pipe must be dewatered so the structural condition of the entire pipe can be assessed.

Acknowledgement and confirmation the above Inspection Submission Requirements have been met. *

I acknowledge and confirm all the above Inspection Submission Requirements have been met.

Inspection Property Street Address *

City *

Zip Code *

Date of PSL Inspection * +

Lateral is defective per the County Code Section 126-700 definition. *

Yes

Contractor First and Last Name *

Contractor Business Name *

Contractor License Number *

Contractor Email Address *

Contractor Street Address *

Address Line 2

City *

Zip Code *

Contractor Phone *

Property Owner First Name *

Property Owner Last Name *

Property Owner Phone

Property Owner Email Address

Start Location *

End Location *

Pipe Size *

Pipe Material *

Cleanout Depth *

Total Pipe Length *

Video Notes (include the time stamp or footage with each description)

Other Notes and Observations (In a separate upload, provide a sketch referencing the street, location of sewer placement, large trees within 20 feet of the PSL, and accessory buildings.)

Rebate Disqualification Acknowledgement *

Any omissions of required documentation will result in an automatic disqualification for the sewer customer to receive a PSL inspection rebate.

Confirmation *

In accordance with Pinellas County Code Section 126-703(a)(2), and subject to the penalties provided therein, I/we declare that the information contained in this Sewer Lateral Video Report Form is true and correct. I/we certify that all of the foregoing information is accurate and that all work was done in compliance with Pinellas County Private Sewer Lateral Video Inspection requirements and meets the requirements of Pinellas County Code.

First and Last Name for Confirmation *