Sewage Application Record Rider Form

Chester County Health Department
Sewage Application Record Form & Sewage Application Rider
Permit Application #
(# on Sewage Application including letter. i.e., Z12345)
Who is the applicant?
Applicant
Property Owner
Equitable Owner
Applicant Mailing Address
Street
City
State
Zip Code
State
Zip Code
Site Address
Street
City
Phone
Email
Site Municipality
Subdivision Name
Lot #
--
UPI Number
Signature of
System Activity
Parent Parcel
--
Property Owner
Equitable Owner
Signature of
New
Permit Class
Modification
Repair
Major
Minor
Property Owner
Equitable Owner
Reason for Repair
Component Replacement
System Failure/Malfunction
Unsatisfactory Certification
Certifier Name
Type of Facility to be Served by this System
# Bedrooms
Residential - Single Family
Residential - Multiple Family
Non-Residential/Commercial
Attach Certifications
# Gal/Day
1 EDU = 400 gpd
# EDUs non-residential only
Location of Property: Please draw or provide clear, narrative directions to the address where the system is
located in the box below. Please give directions with the Government Services Center as the starting point. This
section MUST be completed.
For Dept. Use Only
Admin. Fee:
Receipt:
Date:
Initial Fee:
Receipt:
Date:
Add. Fee:
Transfer Fee:
Receipt:
Date:
Receipt:
Date:
Admin. Fee is non-refundable
rev 6/11/15
Chester County Health Department
Sewage Application Rider
Permit Application #
I, We,
owner(s)
Property Owner
of the real property located in property located in the township of
Equitable Owner
County of Chester and Commonwealth of Pennsylvania more specifically described as follows:
--
UPI Number
--
Site Address:
Street
City
State
Zip Code
do hereby authorize, empower and appoint:
Name
Phone
Address:
my lawful agent exclusively and specifically with reference to the installation of an on-lot sewage disposal system(s) on the
property described above. My agent herein named is authorized, among other things to file applications, conduct tests, attend
meetings, receive notices, and to do any and all other acts necessary for the permitting and installation of said system(s). My
agent is specifically authorized, in my absence, to receive the notice required by 35 P.S. 750.7 Et. Seq.
Signature of
Signature of
Property Owner
Equitable Owner
Property Owner
Equitable Owner
Mail to:
Chester County Health Department
601 Westtown Rd., Suite 288
P.O. Box 2747
West Chester, PA 19380-0990
For Departmental Use Only
Test Pit Observations on __________________at______________ Initial Presoak on __________________at _____________
Perc Test On __________________at ______________________
___ The above dates meet the 20 working day requirement of Act 537.
___ The above dates do not meet the 20 working day requirement of Act 537. The dates given have been mutually agreed to
by the property owner or his assigned agent and the Chester County Health Department.
rev 6/11/15