ࡱ > * bjbjOHOH I2 -"c-"c \ \ 8 $ , X = = S S S $ E S S 4 + + + F S S + + + + S Pv + ( 0 X + ! ! + ! + h + v X ! \ g : APPLICATION/AGREEMENT for HOLDING TANK INSTALLATION PROPERTY OWNER INFORMATION Name Mailing Address City/Town State Zip - Daytime telephone number - - PROPERTY LOCATION Street, Road, Route City/Town Zip - APPLICATION FOR (check one) F i r s t T i m e I n s t a l l a t i o n ( I f t h i s i s c h e c k e d , g i v e T o w n s O r d i n a n c e a d o p t i o n d a t e / / ) F i r s t T i m e I n s t a l l a t i o n , n o n - r e s i d e n t i a l o n l y , l e s s t h a n 1 0 0 g p d o r 5 0 0 g a l / w e e k R e p l a c i n g a n e x i s t i n g o v e r b o a r d d i s c h a r g e , s u r f a c e w a s t e w a t e r d i s c h a r g e o r m a l f u n c t i o n i n g s u b s u r f a c e w a s t e w a t e r s y s t e m R e p l a c i n g a n e x i s t i n g h o l d i n g t a n k C O N D I T I O N S F O R A P P R O V A L * T h e i n s t a l l a t i o n o f a c o n v e n t i o n a l d i s p o s a l s y s t e m i s n o t p o s s i b l e d u e t o u n a c c e p t a b l e s i t e a n d / o r s o i l c o n d i t i o n s , l o t c o n f i g u r a t i o n , o r o t h e r constraints * Public sewer is not available. * All existing or proposed plumbing fixtures shall be installed or modified for water conservation and all water closets shall meet the Federal standard of 1.6 gallons per flush. REQUIREMENTS FOR APPROVAL A Completed Application shall consist of: * This form (HHE-233) completed with all signatures. * A completed Subsurface Wastewater Disposal System Application (HHE-200) prepared by a Licensed Site Evaluator. * Holding Tank Deeds Covenant Form, HHE-300 3/97 * Replacement System Variance Request Form, as necessary. PROPERTY OWNER INFORMATION AND REQUIREMENTS I (we), own the property described in this Application/Agreement. 1. Holding tanks require regular pumping by a licensed pumper. The owner must pay this service. 2. The holding tank will be pumped at least once a year by the pumper listed on this application. Another pumper may be used if the listed pumper is notified and the LPI approves the change. The new pumper will then be listed on an attachment to this agreement. 3. A water meter shall be installed at the owners expense if required by the LPI. 4. All records of pumping and water use (if required) must be kept for at least three years and shall be made available to the LPI or other official if requested. 5. A holding tank for new construction can only be replaced by a system meeting first time system requirements. 6. Once approved this form must be recorded at the Registry of Deeds, cross referenced to the owners deed. 7. We agree to comply with any additional requirements of the Town. We state that all the information presented with this application is true and accurate, we acknowledge the foregoing items and agree to comply with all the requirements. Property Owner(s) Signature Date Property Owner(s) Signature Date SITE EVALUATION STATEMENT I, , state that I have evaluated the subject property and found that a subsurface wastewater disposal system is not practical. Secondly, I have completed a Subsurface Wastewater Disposal System Application (HHE-200) proposing a holding tank installation for the propertys wastewater disposal. Site Evaluators Signature Date HOLDING TANK PUMPER INFORMATION Business owners name License # Business name Mailing address City State Zip - Business telephone - - Max. truck hauling capacity gallons Can pump: seasonally year round DEP licensed disposal site location Site # HOLDING TANK PUMPER STATEMENT I, , own and operate a septage pumping business named in this Application/Agreement, and have contracted with the property owner(s) to pump and properly dispose of the tanks waste. I further state that the tank, and that the wastewater will be disposed of at a Department of Environmental Protection licensed disposal location. Holding Tank Pumpers Signature Date Municipal Officers Statement I (we) have reviewed the information submitted in support of this application. I (we) find that the installation of the holding tank will not violate any local ordinances. I (we) will authorize the LPI to enforce the requirements of this agreement, the Subsurface Wastewater Disposal Rules and any local ordinances, including record-keeping and required pumping. I (we) recommend that the LPI issue the necessary permits for the installation of the holding tank. Signature Title Date Signature 5 6 Q Y e w # $ v ^ ` b X Z v n 0 3 y S P Q ' * hHKE CJ hGG CJ hGG 5CJ hY 6CJ hY 5CJ OJ QJ hY >*CJ hY CJ hY 5CJ hY hY 5CJ hHKE 5CJ F 5 6 Q R f $ % A \ , V 0 d$ ` d$ $a$ 4 j R S + 4 , P - d$ ^ @ @dh ^@`gdD @ @dh ^@`gdGG 0d$ ^`0 d$ * , I P W [ ] w { L 0 ; M X _ f n p u y < @ F ( ( ( ( ( !( '( /( 3( :( =( >( ?( c( <) c) d) n) w) ~) hY U hY 6CJ hY 5CJ hHKE >*CJ hY >*CJ hY CJ h Z >*CJ R- w x < Y z = 1 ] d$ ^ d$ ( >( ?( d( !) 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