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SEWER AND WATER CERT Revised: 01/07/2013 WATER AND/OR SEWAGE DISPOSAL SYSTEM CERTIFICATION ALPINE COUNTY HEALTH DEPARTMENT 75-B Diamond Valley Road Markleeville, CA 96120 (530) 694-2146 (530) 694-2252 fax APPLICANT INFORMATION: BUYER’S NAME TELEPHONE MAILING ADDRESS CITY, STATE, ZIP PERSON REQUESTING CERTIFICATION: COMPANY TELEPHONE MAILING ADDRESS CITY, STATE, ZIP CONTACT NAME ESCROW NUMBER PROPERTY INFORMATION: ADDRESS TOWN APN SUBDIVISION WATER SYSTEM INFORMATION: Individual System Public System 1. Bacteriological Results: Name of System Date: 2. Inspection Date: It is the opinion of the Alpine County Health Department that this individual water supply system is is not satisfactory at the present time as a domestic water supply for the subject property. SEWAGE DISPOSAL SYSTEM INFORMATION: Individual System Public System 1. Tank pumped date: Name of System 2. Inspection date: It is the opinion of the Alpine County Health Department that this individual sewage disposal system was was not failing at time of inspection. APPROVED BY: ENVIRONMENTAL HEALTH SPECIALIST DATE