Suffolk County Department of Health Services
Office of Wastewater Management
360 Yaphank Avenue, Suite 2C
Yaphank, New York 11980
(631) 852-5700 OR HealthWWM@suffolkcountyny.gov
CERTIFICATION OF SEWAGE DISPOSAL SYSTEM ABANDONMENT
Health Department Reference Number: ____________________________________________________
Suffolk Tax Map #: Dist: __________Sect(s)_______________Blk(s)_________Lot(s)______________
Project Name or Address: _______________________________________________________________
Subdivision Name & Lot #_______________________________________________________________
Applicant Name:______________________________________________________________________
I HEREBY CERTIFY THAT:
1. The first septic tank/leaching pool, from the foundation, was located and uncovered, AND
2. If liquid sewage was noted therein, was pumped dry by a licensed sewage hauler, AND
3. Tank/pool was inspected for outlet line to an overflow pool, AND
4. Overflow pool(s) was/were located, uncovered and items #2 and #3 were repeated until all parts of
sanitary system were located, AND
5. All parts of sanitary system were removed or filled with clean backfill and any corbelled block domes
collapsed.
I also certify that the sanitary system abandoned consisted of:
First tank/pool _____feet diameter_____ feet deep ( )precast ( )block ( ) other___________
First overflow pool _____feet diameter_____ feet deep ( )precast ( )block ( ) other___________
Next overflow pool _____feet diameter_____ feet deep ( )precast ( )block ( ) other___________
Next overflow pool _____feet diameter_____ feet deep ( )precast ( )block ( ) other___________
Company which pumped out sanitary system if different from certifying company:
Name of Company:___________________________________________________
Address:___________________________________________________________
Consumer Affairs License Number: _____________
Contractor Signature:_______________________________________________Date__________________
Print Name/Company:____________________________________________Phone_________________
Address:_____________________________________________________________________________
Consumer Affairs License Number: __________________
This certification shall not be used in lieu of inspections required by personnel of the Department
and may be duplicated on company letterhead, provided it contains the above information.
PHOTOCOPIES OF DOCUMENTS WILL NOT BE ACCEPTED
WWM-080 (Rev. 02/12)
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