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2. Date*

   Today's date

4. Name*

   Company name

6. Name 2*

   Installer name

8. Mailing Address*

   Company mailing address

10. Email*

    Company email address

12. CELL PHONE*

    Cell Phone where we can text you.

14. Level*

    Level of Certification

15. Number*

    Certification number

17. Inspector

    1. Yes

    Check if you are an inspector.

18. Subsurface Operator

    1. Yes

    Check if you are a subsurface operator.

20. ACKNOWLEDGMENT

    1. Yes

    By checking this box, you acknowledge the annual requirement to register with Orange County Health Department.  Failure to do so may result in starting with a new registration.  All septic installations must be constructed according to the Orange County Rules for Wastewater Treatment and Disposal, 2024.  

Leave This Blank:


22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

* indicates a required field