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Address:,
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There Is a $100.00 charge for this service. Thls certification Is subject to revocation If the
Intended use of the septic system changes, or If false Information Is provided on this
application.
You signature below certifies that all above information is correct.
Signature of owner or authorized agent:
• . . . • • •
Authorization of Existing System
%nature of Environmental Health Specialist Date
SEPTIC 4108
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