PENNSYLVANIA SEWAGE FACILITIES PROGRAM

APPLICATION FOR SEWAGE INSPECTION

PART I- GENERAL INFORMATION DATE______________________

Name of Property Owner _________________________________________________________________

Address of Property Owner _______________________________________________________________

______________________________________________________________________________________

(City) (State) (Zip)

Telephone No. ( )____________________________________________________________________

Site Address ___________________________________________________________________________

______________________________________________________________________________________

(City) (State) (Zip)

Directions to Site:

______________________________________________________________________________________

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.

X___________________________________________________

SIGNATURE DATE

OWNERS DISCLOSURE OF SEPTIC HISTORY

Circle appropriate answer:

1. What type of septic system do you have? Cesspool Septic Tank & Drain Field Sand Mound or

Elevated system.

Other- Describe ______________________________________________________________________ ______________________________________________________________________________________

2. What is the size of your parcel of land? ___________Acres

3. Is building occupied? Yes No

4. If No, when was the building last occupied? ________________________________________________

5. Are you aware of any sewage back ups, leaks, or problems with your septic system? Yes No

If yes, specify the problems ________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6. When was your septic system last pumped? ________________________________________________

By whom? _____________________________________________________________________

7. Are all drain lines including your kitchen drains and washing machine drains connected to the existing septic system? Yes No

_______________________________ ____________ X .

PRINT NAME DATE SIGNATURE