Dear Agent:

Please provide as much information as possible. Red Fields MUST be filled out.

Thank you for taking the time to fill out the information form.

Date of First Contact with Customer (phone or in person):


New Construction Repair Upgrade
Pre Inspection Performance Inspection Compliance Inspection Require Letter of Assurance Require Statement of Opinion

Email Address of Customer:
Phone Number:
Mailing Address:
Street Address and General Description of lot location:

Sewage System serves:

Single Family Dwelling Duplex Other
Other Description:

Number of Bedrooms:
Is there a finished basement:
Is there an intention to add a basement suite or more bedrooms in future?:
Total Living area of home:
Lot Size (acres, sq ft, or sq m):

Do you know the type of Sewage Disposal System:

Conventional Privy Lagoon Holding Tank Raised Mounds Seepage Bed Trench Other
Other Description:

Do you know if the tank is concrete, fibreglass, or polyethylene:
Volume of Tank or dimensions:
Are there any pumps associated with the system inside or outside:
Is a garburator in the household:

Site Information:

Is there a known high water table in the area:
Describe the source of domestic water:
Distance of disposal field to domestic water:
Are there any covenants or easements on property:
Do you have a sketch that shows where tank and drainfield may be located: