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Get Wwm 078 2018-2024

Yes I hereby certify that the subsurface sewage disposal system described herein has been installed by me in accordance with the approved plans and standards of the Suffolk County Department of Health Services and any and all mechanical/electrical components have been tested and are operational. Installer s Signature Date Installer s Name Company Name Phone Company Address Consumer Affairs Liquid Waste License Number and endorsement s THIS DOCUMENT MUST CONTAIN AN ORIGINAL SIGNATURE FROM THE INSTALLER WWM-078 04/18. Suffolk County Department of Health Services Office of Wastewater Management 360 Yaphank Avenue Suite 2C Yaphank New York 11980 631 852-5700 OR HealthWWM suffolkcountyny. gov CERTIFICATION OF SEWAGE DISPOSAL SYSTEM BY INSTALLER This certification shall not be used in lieu of inspections required by personnel of the Department and may be duplicated on company letterhead provided it contains the information below. Leave blank any items that are not applicable to the installation Health Department Reference Number Suffolk Tax Map Dist Sect s Blk s Lot s Project Name or Address Applicant s Name Date of System Installation Sketch below the measurements from building I/A OWTS TREATMENT UNIT corners to the access covers/ports of disposal system or attach a separate sketch prepared by installer Make and Model Rated Daily Treatment Capacity gallons Material Concrete Fiberglass/Plastic SEPTIC TANK Volume gallons Shape Rectangular Cylindrical Top Slab Traffic Slab Dome Name of Tank Manufacturer DISTRIBUTION LEACHING POOLS If applicable Number of Pools Diameter and Effective Depth Name of Precast Manufacturer LEACHING POOLS/GALLEYS Total Number of Pools/Galleys Diameter/Dimensions and Effective Depth Top Slab N/A OTHER LEACHING STRUCTURES Total Linear Feet of Leaching Structure s COVERS AND LIDS Installed covers comply with current standards secondary safety device installed if cover weight less than 60lbs. Suffolk County Department of Health Services Office of Wastewater Management 360 Yaphank Avenue Suite 2C Yaphank New York 11980 631 852-5700 OR HealthWWM suffolkcountyny. gov CERTIFICATION OF SEWAGE DISPOSAL SYSTEM BY INSTALLER This certification shall not be used in lieu of inspections required by personnel of the Department and may be duplicated on company letterhead provided it contains the information below. gov CERTIFICATION OF SEWAGE DISPOSAL SYSTEM BY INSTALLER This certification shall not be used in lieu of inspections required by personnel of the Department and may be duplicated on company letterhead provided it contains the information below. Leave blank any items that are not applicable to the installation Health Department Reference Number Suffolk Tax Map Dist Sect s Blk s Lot s Project Name or Address Applicant s Name Date of System Installation Sketch below the measurements from building I/A OWTS TREATMENT UNIT corners to the access covers/ports of disposal system or attach a separate sketch prepared by installer Make and Model Rated Daily Treatment Capacity gallons Material Concrete Fiberglass/Plastic SEPTIC TANK Volume gallons Shape Rectangular Cylindrical Top Slab Traffic Slab Dome Name of Tank Manufacturer DISTRIBUTION LEACHING POOLS If applicable Number of Pools Diameter and Effective Depth Name of Precast Manufacturer LEACHING POOLS/GALLEYS Total Number of Pools/Galleys Diameter/Dimensions and Effective Depth Top Slab N/A OTHER LEACHING STRUCTURES Total Linear Feet of Leaching Structure s COVERS AND LIDS Installed covers comply with current standards secondary safety device installed if cover weight less than 60lbs. .

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