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2. Account Number*
3. First Name on Account*
4. Last Name on Account*
6. Service Address*
8. Date(s) of Repair*
9. Date(s) of Refill*
11. Brief description of repair. Proof of repair is required and must be submitted with this form. Repair must be submitted within 90 days after the date of the repair for eligibility.*
13. Per the Development Services website, “A permit is required for the construction or repair of any building, structure, plumbing system, electrical system, or mechanical system in the City as per City of Sachse Code of Ordinances.”
15. Was Development Services contacted to confirm permit requirements?*

    1. Yes
    2. No
16. If permit was obtained, please provide permit #:
17. If no, please contact Development Services 469-429-4781 to ensure your repairs do not require a permit.
19. Please note, obtaining a permit is not required in order to move forward with the adjustment review.
21. Previous repair adjustment request has occurred within the past 12 months

    1. Yes
    2. No
22. Upload Proof of Repair*

    Acceptable forms are: itemized receipt of repair parts, plumber invoice, receipt from a pool technician or other documentation supporting repairs.

23. Gallons used for repair and refill

    Please enter the estimated number of gallons used for repair and refill of your swimming pool.

25. Email Address*

    I hereby apply for an adjustment under the City of Sachse's Code of Ordinances. I certify that the above and attached information are true and accurate.

Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit Submit and Print

* indicates a required field