OK DEQ On-Site Service Request Form

Request for On-Site Services Form

Please read the following instructions carefully before filling out form

* Indicates Required Field

Please enter phone and fax numbers in the format (999) 999-9999 OR 999-999-9999

If you provide an email address, the application and payment information will be emailed to you

Please omit all quotation mark while filling application

If you are a Certified Installer, you must use your Certification Number to insure correct billing.
Using your Certification Number will also cause your Requester information to load automatically

It is recommended that a copy of the form 641-581 Report for On-site Sewage Treatment be available to complete the property information and legal description

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REQUESTER INFORMATION Certification Number **

Requester's First Name * ** ** Requester's Last Name * ** **
Contact First Name * ** ** Contact Last Name * ** **
Address * ** ** City * ** ** State Zip * ** **
Contact Phone * ** ** Fax ** Email **

PROPERTY INFORMATION

Current Property Owner First Name * ** ** Last Name * ** **
Property Address * ** ** County Where Property is Located * **
City * ** ** State OK Zip * ** ** Phone **
Subdivision ** Lot ** Block **
Section * ** ** Township * ** ** Range * ** **

REQUESTED SERVICE(S)

FEE

Soil Test

Soil Test (pits provided by applicant)

Clear selection above

$338.08 $202.84

Existing Septic System Evaluation

Existing Private Water Well Evaluation

$338.08 $279.85

Your Total Fee is