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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