HomeMy WebLinkAboutSeptic Correspondence 446 Barber Hill Ro STATE OF CONNECTICUT
DEPARTMENT OF PUBLIC HEALTH
Subsurface Sewage Installer License
Verification of Experience Form
APPLICANT:Complete the t=portion of this form and submit to the Local health Department(LHD).
• Use a separate form for each of the four(4)required installations.
• Applicant must notify LHD of intent to participate in the system installation prior to commencement.
• Only systems installed less than S years before the examination date shall be accepted.
■ System must include installation of leaching system in order to be accepted
• It is applicant's responsibility to submit fully executed forms with application.
■ Applicant shall be onsite during installation and LHD inspections(unless prior arrangement are agreed upon)
Name: A 6C r -z Date of Birth:
-= A'>X'L1+CANT:Dfl N�flT TE BELOti�'THiS L11N-FflR LflCAI.HEALTH IJSE ONLY
System Information
Property Address: y(� Aq Ir-k—e Al i l 2 00 r,
City,state: cJO S& w i Vl d St7� C p to 0 -7
Licensed Installer: License No.:
L.H.D.: Permit No.:
Final Inspection Date:
Was applicant on site at the time of all inspections? "S ❑ NO
Is the installation in accordance with the approved plan? ETyES ❑ NO
Has the LHD issued a permit to discharge? 9-YES ❑ NO
If"No"please explain:
Name: > p
L D Out r"a en, Title: �J Phone:
Signature: P Date:
Local Health Deat: Please return form to applicant once completed The Department recommends that a copy be kept in
the property file.
Applicant: Four separate ver fication forms must be included with your application for exam eligibility.