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Get wwm 078 2012-2024

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 is operational. Installer s Signature Date Installer s Name Company Name Phone Company Address Consumer Affairs Liquid Waste License Number PHOTOCOPIES OF DOCUMENTS WILL NOT BE ACCEPTED WWM-078 02/12. 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. Health Department Reference Number Suffolk Tax Map Dist Sect s Blk s Lot s Project Name or Address Subdivision Name Lot Applicant s Name Date of System Installation Description of System Installed Septic Tank Volume gallons Shape Rectangular Cylindrical Top Slab Traffic Slab Dome Name of Precast Manufacturer Leaching Pools Number of Pools Diameter and Effective Depth Other Sketch below the measurements from building corners to the access covers of disposal system or attach a separate sketch prepared by installer. 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. Health Department Reference Number Suffolk Tax Map Dist Sect s Blk s Lot s Project Name or Address Subdivision Name Lot Applicant s Name Date of System Installation Description of System Installed Septic Tank Volume gallons Shape Rectangular Cylindrical Top Slab Traffic Slab Dome Name of Precast Manufacturer Leaching Pools Number of Pools Diameter and Effective Depth Other Sketch below the measurements from building corners to the access covers of disposal system or attach a separate sketch prepared by installer. 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. Health Department Reference Number Suffolk Tax Map Dist Sect s Blk s Lot s Project Name or Address Subdivision Name Lot Applicant s Name Date of System Installation Description of System Installed Septic Tank Volume gallons Shape Rectangular Cylindrical Top Slab Traffic Slab Dome Name of Precast Manufacturer Leaching Pools Number of Pools Diameter and Effective Depth Other Sketch below the measurements from building corners to the access covers of disposal system or attach a separate sketch prepared by installer. .

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