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PENNSYLVANIA SEWAGE FACILITIES PROGRAM APPLICATION FOR SEWAGE INSPECTION
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| PART I- GENERAL INFORMATION |
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| DATE______________________ |
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| Name of Property Owner _________________________________________________________________ |
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Address of Property Owner ______________________________________________________________
____________________________________________________________________________________
(City) (State) (Zip)
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| Telephone No. ( )___________________________ |
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Site Address __________________________________________________________________________
____________________________________________________________________________________
(City) (State) (Zip)
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Directions to Site:
____________________________________________________________________________________
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Inspection Information
During the inspection for Real Estate Transfer the property owners and /or agents of Real Estate Transfer must have the septic tanks fully pumped out by a licensed pumper. Full access to the top of the septic tank must be made so that the large 20" in diameter concrete lid can be opened for proper pumping and inspection of each tank. This requires digging down to the top of the tank ahead of the scheduled inspection.
I understand the above information and will make sure that the septic tank or tanks are fully accessible as described above just prior to the time of pump out and inspection so as to facilitate an expedient inspection.
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| SIGNATURE X_________________________________________________DATE__________________________________ |
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OWNERS DISCLOSURE OF SEPTIC HISTORY
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| Circle appropriate answer: |
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1. What type of septic system do you have? Cesspool Septic Tank & Drain Field Sand Mound or Elevated system.
Other- Describe ______________________________________________________________________
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| 2. What is the size of your parcel of land? ___________Acres |
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| 3. Is building occupied? Yes No |
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| 4. If No, when was the building last occupied? ___________________________________________________ |
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5. Are you aware of any sewage back ups, leaks, or problems with your septic system? Yes No
If yes, specify the problems ________________________________________________________
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6. When was your septic system last pumped? ________________________________________________
By whom? _________________________________________________________________________
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| 7. Are all drain lines including your kitchen drains and washing machine drains connected to the existing septic system? Yes No |
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_______________________________ ____________ X .
PRINT NAME DATE SIGNATURE
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