PLUMBING APPLICATION
PROPERTY ADDRESS
City, Town, or Plantation
Street/Subdivision Lot #
PROPERTY OWNER INFORMATION
Name (Last, First)
Maine DHHS/CDC - Division of Environmental & Community Health
ISSUING MUNICIPAL OFFICE
Town/City
Permit #
Date Issued
Total Fee $
Double Fee
Applicant Name (Last, First)
Street
City
State
OWNER/APPLICANT MAILING ADDRESS
Zip Code
OWNER/APPLICANT STATEMENT
I certify that the information submitted is correct to the best of my knowledge and understand that any falsification is reason for the Local Plumbing Inspector(s) to deny a permit.
Local Plumbing Inspector Signature
FEES
State $
LOCATION
Map #
License #
Local
Lot #
Internal plumbing fixtures and piping may not be installed until a permit is issued by the Local Plumbing Inspector. The peril authorizes the owner or installer to install the plumbing system in accordance with this application and the Maine Subsurface Wastewater Disposal Rules.
CAUTION: INSPECTION REQUIRED
I have inspected the installation authorized above and found it to be in compliance with the Maine Plumbing Rules Application.
Signature of Owner/Applicant
Date
LPI Signature
Date (Rough-In)
Copy:
Property Owner
Town
State
Date (Final)
PERMIT INFORMATION
This application is for:
New Plumbing
Relocated Plumbing
Type of structure to be served:
Single Family Residence
Modular or Mobile Home
Plumbing to be installed by:
Master Plumber
License #
Oil Burner Installer
License #
Multiple Family Dwelling
Mfd. Housing Rep.
License #
Other (specify below)
Public Utility Rep.
License #
Property Owner
Column 1-Hook-Up & Relocation
Column 2 – Fixtures
Maximum 1 Hook-Up
Hook-Up (a)
Hook-up to public sewer in those cases where the connection is not regulated and inspected by the local sanitary district.
Type of Fixture
Qty
Column 3- Fixtures
Type of Fixture
Qty
State of Maine
Hosebib/Sillcock
Floor Drain
Bathtub (and Shower)
Urinal
Drinking Fountain
Hook-Up (b)
Hook-up to a newly permitted or existing subsurface wastewater disposal system.
Piping Relocation
Relocation of sanitary lines, drains, and piping without new fixtures.
Other:
Indirect Waste
Treatment Softener, Filter, etc.
Grease/Oil Separator
Roof Drain
Bidet
Shower (Separate)
Sink
Wash Basin
Water Closet (Toilet)
Clothes Washer
Dishwasher
Garbage Disposal
Laundry Tub
Water Heater
Department of Health and Human Services/
Center for Disease Control and Prevention
Environmental & Community Health Subsurface Wastewater
286 Water Street State House Station 11 Augusta, ME 04333
207-287-2070
HHE-211 Revised 7/24/2018
Total Column 1
+
Total Column 2
+
ဆက
PERMIT TRANSFER ONLY
$10.00
Total Column 3
Enter Total Fixtures / Hook-Ups Below
Total Fixtures / Hook-Ups
Per-Fixture Fee
$
TOTAL PERMIT FEE
$