Cumberland County Department of Health
309 Buck Street Millville, NJ 08332
(856) 327-7602 x7122 | www.ccdoh.org
<div style="width:580px;font-family:Times,serif;font-size:15px;clear:both;text-align:center;"><b>SEPTIC (FINAL INSPECTION) CERTIFICATE OF COMPLIANCE </b>(<span style="font-family:Times,serif;font-size:12px;"></span>) </div> <div style="width:580px;font-family:Times,serif; font-size:12px; clear:both;"><b>Instructions:</b></div> <div style="height:10px; clear:both;"></div> <div style="width:580px;font-family:Times,serif; font-size:12px;clear:both;margin-left:30px;"> <strong>Part A</strong> is to be completely filled in for all certifications. <div style="height:5px; clear:both;"></div> <strong>Part B</strong> is <b>NOT necessary UNLESS</b> the Cumberland County Health Department relies on the certification signed and sealed by a New Jersey licensed professional engineer and requests signature for the below statement. If signature is NOT requested, this section will be electronically marked “Part B: Engineer Certification is NOT applicable”, otherwise, engineer signature is required. <div style="height:5px; clear:both;"></div> <strong>Part C</strong> is always completed by Cumberland County Health Department (CCHD) for ALL certifications. Either CCHD certifies the compliance statement (Part C) with signature or accepts the engineer certification by signature, when electronically marked "By signature below, the Administrative Authority accepts the Engineer Certification is NOT applicable when Engineer Certification is required by CCHD". </div> <div style="height:10px; clear:both;"></div> <div style="width:580px;font-family:Times,serif; font-size:12px; clear:both;"><b>Part A - </b>General Information:</div> <div style="height:10px; clear:both;"></div> <div style="width:580px;font-family:Times,serif; font-size:12px;clear:both;margin-left:30px;">1. Permitted Activity:</div> <div style="width:580px;font-family:Times,serif; font-size:12px;clear:both;margin-left:42px;">Permit Number: </div> <div style="width:580px;font-family:Times,serif; font-size:12px;clear:both;margin-left:42px;">Permit Type: </div> <div style="height:10px; clear:both;"></div> <div style="width:580px;font-family:Times,serif; font-size:12px;clear:both;margin-left:30px;">2. Location of Activity: <!----></div> <div style="width:580px;font-family:Times,serif; font-size:12px;clear:both;margin-left:42px;"> Municipality: <br/> Block: Lot: <br/> Street: <!----> <br/> </div> <div style="height:10px; clear:both;"></div> <div style="width:580px;font-family:Times,serif; font-size:12px;clear:both;margin-left:30px;">3. Name and present address of owner/applicant:</div> <div style="height:10px; clear:both;"></div> <div style="width:580px;font-family:Times,serif; font-size:12px;clear:both;margin-left:75px;"> <br/> <br/> </div> <div style="width:580px;font-family:Times,serif; font-size:12px;clear:both;margin-left:75px;"> </div> <div style="height:10px; clear:both;"></div> <div style="width:580px;font-family:Times,serif; font-size:12px; clear:both;"><b>Part B - Professional Engineers Certification</b></div> <div style="height:2px; clear:both;"></div> <div class="part-b-no" style="display:none;width:100%;border:solid 1px #000;color:red;text-align:center;padding:10px;"> ENGINEER CERTIFICATION IS <B>NOT</B> APPLICABLE </div> <div class="part-b-yes" style="display:block;"> <div style="width:580px;font-family:Times,serif; font-size:12px; clear:both;"> I certify under penalty of law that the subsurface sewage disposal system identified in Part A has been located, constructed, installed, or altered in compliance with the requirements of N.J.A.C 7:9A-1 and the Administrative Authority. </div> <div style="height:10px; clear:both;"></div> <div style="width:580px;font-family:Times,serif;font-size:12px;clear:both;"> <div style="width:180px;float:left;line-height:20px;height:auto;">_____________________________________________</div> <div style="width:108px;float:right;display:block;margin:0 0 0 5px;line-height:20px; height:auto;"> ____________</div> </div> <div style="width:580px;font-family:Times,serif;font-size:12px;clear:both;"> <div style="width:240px;float:left;line-height:20px;height:auto;"> Signature </div> <div style="margin-left:20px;float:left;">(Seal)</div> <div style="width:90px;float:right;display:block;padding:0 0 0 30px;line-height:20px;height:auto;">Date</div> </div> <div style="height:10px; clear:both;"></div> <div style="width:580px;font-family:Times,serif;font-size:12px;clear:both;"> <div style="width:150px;float:right;display:block;padding:0 0 0 30px;line-height:20px;height:auto;">License #___________</div> </div> </div> <div style="height:15px; clear:both;"></div> <div style="width:580px;font-family:Times,serif; font-size:12px; clear:both;"><b>Part C - Certification by Administrative Authority</b></div> <div class="part-c-no" style="display:block;width:100%;border:solid 1px #000;color:red;text-align:center;padding:10px;"> By signature below, the Administrative Authority accepts the Engineer Certification as stated above (Part B) in lieu of CCHD Certification pursuant to NJAC 7:9A-3.13. </div> <div class="part-c-yes" style="display:none;"> <div style="width:580px;font-family:Times,serif; font-size:12px; clear:both;display:none;"> I certify the system identified above is in compliance with NJAC 7:9A and the approved plans. </div> <div style="height:10px; clear:both;"></div> <div style="width:380px;font-family:Times,serif;font-size:12px;clear:both;"> <div style="width:180px;float:left;line-height:20px;height:auto;">_______________________________</div> <div style="width:108px;float:right;display:block;margin:0 0 0 5px;line-height:20px; height:auto;"> ____________</div> </div> <div style="width:380px;font-family:Times,serif;font-size:12px;clear:both;"> <div style="width:240px;float:left;line-height:20px;height:auto;">Licensed REHS Name</div> <div style="width:90px;float:right;display:block;padding:0 0 0 30px;line-height:20px;height:auto;">Date</div> </div> </div> <div style="height:10px; clear:both;"></div> <div style="width:580px; border-bottom: #ccc 1px solid; line-height:1px; padding:5px 0;"></div> <div style="height:10px; clear:both;"></div>
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