July 2019
MARICOPA COUNTY ENVIRONMENTAL SERVICE DEPARTMENT
WATER & WASTE MANAGEMENT DIVISION
ONSITE WASTEWATER PROGRAM
501 North 44th Street, Suite 200, Phoenix, AZ 85008
Phone: (602) 506-6666 Fax: (602) 506-6925
Email: SepticQuestions@maricopa.gov Website: esd.maricopa.gov
CERTIFICATION THAT CLOSURE/ABANDONMENT OF AN
ONSITE WASTEWATER TREATMENT FACILITY IS COMPLETED
CLOSURE/ABANDONMENT PERMIT NUMBER OWR-
APN: - -
SITE ADDRESS:
PROPERTY OWNER:
MAILING ADDRESS:
PERMIT NUMBER OF THE CLOSED/ABANDONED SYSTEM
CLOSU
RE/ABANDONMENT OF THIS ONSITE WASTEWATER TREATMENT FACILITY WAS COMPLETED IN
COMPLIANCE WITH ALL APPLICABLE RULES AND CODES ON:
mm/dd/year:
________
/
________
_/20
_______
REASO
N FOR CLOSURE/ABANDONMENT:
REPLACEMENT SYSTEM TO BE INSTALLED, PERMIT NUMBER _____
NO REPLACEMENT, FUTURE USE OF PARCEL UNKNOWN AT THIS TIME
DEMOLITION OF CONNECTED STRUCTURES
SYSTEM IS NO LONGER IN USE
CONNECTED TO SEWAGE COLLECTION SYSTEM
NAME OF CITY OR SEWER DISTRICT:
COMPANY NAME: AZ ROC LICENSE:
CONTRACTOR SIGNATURE: _ DATE:
PROPERTY OWNER/AGENT SIGNATURE: DATE:
RETURN THIS COMPLETED CERTIFICATION AND ALL REQUIRED ATTACHMENTS TO MCESD, ONSITE WASTEWATER
PROGRAM BY MAIL, IN PERSON, E-MAIL TO SEPTICQUESTIONS@MARICOPA.GOV OR FAX TO (602) 506-6925.
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