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
$338.08 $202.84
$338.08 $279.85
Your Total Fee is