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City, Town, or Plantation PERMIT INFORMATION PROPERTY ADDRESS PROPERTY OWNERS NAME Street or Road Subdivision, Lot # Name (last, first, MI) Mailing Address of Owner/Applicant Daytime Tel. # PLUMBING APPLICATION This Application Is For 1. NEW PLUMBING INSTALLATION 2. RELOCATED PLUMBING Type of Structure To Be Served 1. SINGLE FAMILY DWELLING 2. MODULAR OR MOBILE HOME 3. MULTIPLE FAMILY DWELLING 4. OTHER-SPECIFY Plumbing To Be Installed By 1. MASTER PLUMBER 2. MFG'D HOUSING DEALER/MECHANIC 3. PUBLIC UTILITY EMPLOYEE 4. PROPERTY OWNER LICENSE # I I I I I I HOOK_UP: to an existing subsurface wastewater disposal system PIPING RELOCATION: of sanitary lines, drains, and piping without new fixtures OR OR TRANSFER FEE ($10.00) Fixtures (Subtotal) Column 1 Total Fixtures Total Fixtures Permit Fee (Total) Hosebibb / Sillcock Floor Drain Urinal Drinking Fountain Indirect Waste Waste Treatment Softener, Filter, etc. Grease / Oil Separator Dental Cuspidor Bidet Other: Fixtures (Subtotal) Column 2 Bathtub (and Shower) Shower (Separate) Sink Wash Basin Water Closet (Toilet) Clothes Washer Dish Washer Garbage Disposal Laundry Tub Water Heater Fixtures (Subtotal) Column 2 Fixture Fee Transfer Fee Hook-Up & Relocation Fee Maine Dept.Health & Human Services Div of Environmental Health , 11 SHS (207) 287-5672 Fax: (207) 287-4172 CAUTION: LPI APPROVAL REQUIRED Town/City Permit # Date Permit Issued Fee: Double Fee Charged [ ] L.P.I. # Local Plumbing Inspector Signature Owner Town State rev. 08/2011