Affidavit To Replace Designer Of Record Form - Rhode Island Department Of Environmental Management
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1For office use only
Application number _______________________________ Application Date________________
RHODE ISLAND DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
Onsite Wastewater Treatment Program
Office of Water Resources, Room 260
235 Promenade Street, Providence, RI 02908-5767
AFFIDAVIT TO REPLACE DESIGNER OF RECORD
I ______________________________________________ said owner(s) of property, OWTS permit number
(print name)
_________________________, do hereby request authorization to have the replacement designer
_______________________________________________________ witness and inspect the installation of
(designer name and license number)
the OWTS on said property. I am petitioning the Department for this request based on the following reason(s):
CHECK APPROPRIATE ITEM(S):
1) _____ The original designer of the system is incapable of witnessing and inspecting the system because
he/she is:
_____Deceased
_____Physically Incapacitated
_____No Longer Licensed
_____ Other_____________________________________________
2) _____ I, the property owner, contracted with a certain business entity for design services. The original
designer who prepared the OWTS design is no longer employed by that business entity, and the
property owner is replacing the original designer with another designer employed by that business
entity.
Owner(s) signature: __________________________________________ Date: _______________
(Owner must be the same person as permitee)
I, the replacement designer, have a designer’s license in the appropriate license class required by the
rules to design the system prepared by the original designer of said OWTS. I take full responsibility for
the design and installation of the system in accordance with all OWTS Rules.
Replacement designer’s signature: ______________________________ Date: _______________
FOR OFFICE USE ONLY
DECISION: Approved
Denied
Comments_______________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Signature of Authorized Agent_________________________________________ Date__________________________
12-10-08
Affidavit Replace Designer of Record
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