ETApplication # 13 �— /r !
Property
Property Address:
Name of
J, -
R Number
Specific Directions to Job from LillingLon:
There Is a $100.00 charge for this service. This certification Is subject to revocation if th%-§
Intended use of the septic system changes, or If false information Is provided on this
f •
You • below certifies ♦. e:9 info-rmation is corre f..
Signature of owner or authorized agent:
i
20
Signature of
•
Specialist
end gl3
q112,113 'S