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PLUMBING APPLICATION HHE-211 Maine CDC Drinking Water Program / Subsurface Wastewater PROPERTY ADDRESS ISSUING MUNICIPAL OFFICE Street / Subdivision Lot # Town / City PROPERTY OWNER INFORMATION Permit # Total Fee $ Name (Last, First) Date Issued Double Fee Applicant Name (Last, First) OWNER/APPLICANT CONTACT INFORMATION Local Plumbing Inspector Signature License # Street FEES State $ Local $ City LOCATION Map # Lot # State Zip Code Phone Internal plumbing fixtures and piping may not be installed until a permit is issued by the Local Plumbing Inspector. The permit authorizes the owner or installer to install the plumbing system in accordance with this application and the Maine Subsurface Wastewater Disposal Rules. Email OWNER/APPLICANT STATEMENT I certify that the information submitted is correct to the best of my knowledge and understand that any falsification is reason for the Local Plumbing Inspector(s) to deny a permit. CAUTION: INSPECTION REQUIRED I have inspected the installation authorized above and found it to be in compliance with the Maine Plumbing Rules Application. Owner/Applicant Signature Date LPI Signature Date (Rough-In) Copy: Property Owner Town State Date (Final) PERMIT INFORMATION This application is for: Type of structure to be served: Plumbing to be installed by: New Plumbing Single Family Residence Master Plumber License # Relocated Plumbing Modular or Mobile Home Mfd. Housing Rep. License # HUD Homes (permanent frame) Multiple Family Dwelling Property Owner Certified Modular Home Other (specify below) Column 1 – Hook-Up & Relocation Column 2 – Fixtures Column 3 – Fixtures State of Maine Department of Health and Human Services/ Center for Disease Control and Prevention Environmental & Community Health ● Drinking Water Program ● Subsurface Wastewater 286 Water Street State House Station 11 Augusta, ME 04333 [PHONE REDACTED] HHE-211 Revised 3/7/2024 Maximum 1 Hook-Up Type of Fixture Qty Type of Fixture Qty Hook-Up Treatment Softener, Filter, etc. Bathtub (and Shower) Hook-up to public sewer in those cases where the connection is not regulated and inspected by the local sanitary district. Hosebib/Sillcock Shower (Separate) Floor Drain Sink Urinal Wash Basin Hook-Up Drinking Fountain Water Closet (Toilet) Hook-up to a newly permitted or existing subsurface wastewater disposal system. Indirect Waste Clothes Washer Grease/Oil Separator Dishwasher Piping Relocation Roof Drain Garbage Disposal Relocation of sanitary lines, drains, and piping without new fixtures within the structure. Bidet Laundry Tub Other: Water Heater Total Column 1 + Total Column 2 + Total Column 3 = Enter Total Fixtures / Hook-Ups Below PERMIT TRANSFER ONLY $10.00 Total Fixtures / Hook-Ups Per-Fixture Fee $ TOTAL PERMIT FEE $