Lake Power Of Attorney - Lake County Health Department
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1LIMITED POWER OF
ATTORNEY
Date:
I hereby name and appoint:
of
to be my true and lawful limited attorney-in-fact to act on my behalf to:
1. Apply to the Florida Department of Health in Lake County Environmental Health for all
Onsite Sewage Treatment and Disposal System (OSTDS) permits for a period
of_________________(years and/or months).
Name of Certified Contractor or Property Owner (Type or Print)
/
/
Signature of Certified Contractor or Property Owner
Date
.
Contractor License Number (if applicable)
State of
County of
The foregoing instrument was acknowledged before me this
day of
, 20
, by
who is personally known
to me or has produced
as identification and who did
or did not
take an oath.
.
Notary Public
Commission expiration date:
Rev. 04-2013
EHShare/OSTDS Forms/Power of Attorney Form
Florida Department of Health in Lake County Environmental Health
P.O. Box 1305 Tavares, FL 32778-1305
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