NOTIFICATION OF INSTALLATION AND UNDERTAKING
TO MAINTAIN A SEWAGE HOLDING TANK
INSTRUCTIONS:
1. The owner or agent shall contact Environmental Health Office at least 72 hours before backfilling.
2. Details of any variation from the system proposed and a copy of the appropriate authorization of such
variation must be supplied with this notification.
3. Attach photographs of the system installed, indicating clearly its layout, components (including the high
level indicator), design features and location on the property. Identify on the back of each photograph
the legal description and permit number.
4. Prior to the issuance of the letter indicating the completion of the permitting process
(should the installation appear satisfactory), this form and attached photographs are to be submitted to:
Environmental Health Services • #2 Hospital Road, Whitehorse, Yukon Y1A 3H8
phone: (867) 667-8391 • fax: (867) 667-8322 • e-mail: Environmental.Health@gov.yk.ca
NOTIFICATION:
Please be advised that an Environmental Health Officer (EHO) was notified (prior to backfilling) that on
___________________ a sewage holding tank was being installed by self
or:
(date)
Name of installer:
__________________________________________________________
Phone number:
__________________________
Fax number:
__________________________
at _____________________________________________________________________________________
(legal description, municipal address, if applicable & plan number)
and that said system was installed in accordance with the permit numbered ___________________________
issued on ___________________.
(date)
UNDERTAKING:
As the owner of the above listed property, I undertake to:
•
inspect and monitor the septic system periodically for integrity and operation;
•
maintain and utilize the system so as to protect the environment and human health;
•
protect the system from vehicular traffic; and
•
provide an approved means of safely disposing of the sewage.
Name of Eduction (pump-out) services: __________________________________________________
Phone number:
__________________________
Fax number:
__________________________
Or describe other arrangements: _____________________________________________________________
_______________________________________________________________________________________
Signature of owner: _____________________________
Print name: _______________________________
Address: ___________________________________________________ Postal Code: _________________
Signature of witness: ____________________________
Print name: _______________________________
Date signed: ______________________________
YG(4673EQ)F2 Rev. 01/2006
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