Property Owner's First Name:  
 

Property Owner's *Last Name   

(* Please note that the name submitted must match City of Milwaukee property records.) 

Property Street Address:  

City:   State:    ZIP: 

Phone number 1          Mobile     Land line

Phone number 2           Mobile    Land line

Email address 1 

Email address 2 

Number of dwelling units at this property 1234

Does this property have any commercial purpose, per the Office of the City Assessor?    Yes    No 

Submit 4-5 photographs of the water meter and surrounding area:

• Include the meter in each photo, and take multiple photos from various distances from the meter (1. Close up, 2. From  three feet away, 3. From 5-10 feet away, 4. From 10-15 feet away, 5. From 15-20 feet away.) Water Works will need to confirm that there are no obstructions to accessing the meter on the day of construction.
   
  
• IMPORTANT NOTE: Uploaded files are stored separately from the rest of the data submitted with the form. Therefore, the file name for each photograph must include the property address or Water Works staff will not be able to associate your photos with the appropriate property. If you are taking photos with an iPhone, save the images to the iPhone "Files" app first, which allows a user to modify the file name, then upload to this form. Or, save the photos to a desktop computer so you can rename each image file prior to uploading them to this form.  

Submit photo #1 here:  
Submit photo #2 here:  
Submit photo #3 here:  
Submit photo #4 here:  
Submit photo #5 here:  
 

 I understand that I will be required to pay 100% of the actual cost to replace the privately-owned portion of the lead service line, or the current average cost, whichever is less. 

  I understand that I will receive an invoice by mail, and can pay the invoice in full within 45 days of the postmarked date, or as a special assessment on my property tax bill. (Invoices are mailed out once per year, on or shortly after September 1.)

  I understand that if I elect to pay over time as a special assessment, my debt will accrue interest at the current Prime Rate plus 1%.

 I understand that I must fill out, sign, and return two forms: 

1) The "Election to Use City Contractor to Replace Lead Service Line and Install Meter Setting form, which authorizes a City-designated contractor to perform work on my property, and 

2)  The "Temporary Right-of-Entry, Construction Easement, and Hold Harmless Agreement", which authorizes a City-designated contractor to enter my property to perform the necessary work, and includes a Scope of Work. 

 I understand that the Owner Request Replacement Option Program is subject to the capacity of Milwaukee Water Works and its designated contractors, and may be influenced by the number of emergency and planned lead service line replacements in any given year, as well as other factors, and that there is no guarantee that my service line will be replaced in the same year that I make this request, and that the determination to proceed with the work on my property rests with Milwaukee Water Works. 
 

 Children under the age of 6 reside at this property. (Do not check if there are no children under 6 years old.)

      Please indicate the ages of children younger than six years old: 

      Child age: 

      Child age: 

      Child age: 

 Children between the age of 6 and 18 years reside at this property. (Do not check if there ae no children between 6 and 18 years old.)

      Please indicate the ages of the children who are between 6 and 18 years old: 

      Child age: 

      Child age: 

      Child age: 

If you have any questions, please email us at [email protected], or call 414-286-6304, or indicate your questions here (limit 500 characters):