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ON-SITE SEWAGE SYSTEM CONTRACTOR FORM Fee: $25 Business Name: Owner: Address: City, State, Zip: Phone: Email: Certifications: ATL ☐ Presby ☐ Drip Irrigation ☐ Other: *provide copy of certifications* Date : Signature: January 2024 18030 Foundation Drive, Suite A Noblesville, In 46060 Phone: (317) 776-8500 or Fax: (317) 776-8506 Charles Harris, MD - Health Officer