E-Gov Services Peters Township

Pothole

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Purpose. Use this form to report a pothole.

* Information is required.

Contact Information

* First Name:
* Last Name:
Business Name:
Email:
* Daytime Phone:	() –
Fax:	() –
* Address:
* City:
State:
ZIP:

* Location of pothole (be as specific as possible).

* Size of pothole

Small (less than 12 inches across)

Medium (12-24 inches)

Large (over 24 inches)

Special Circumstances

Is creating traffic hazard

On major street

What type of Road is it if known?

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* Information is required.

Notes:

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Internal Use Only, Leave Blank:
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