Georges Pond Association

Date *

MM

DD

YYYY

Name *

First Name

Last Name

Phone *

(###)

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Qualifications to Apply *

Yes, I know where my septic system is located.

Yes, I will provide the GPA with a map/drawing of the location of my septic system.

No, I do not know the location of my septic system.

Date of installation (if known)

MM

DD

YYYY

Check any that apply:

My septic system is used year-round

My camp is rented out

Permission for Inspection in Absentia *

Yes, I give permissino for an inspection in my absence as long as an authorized GPA board member is present.

No, I do not give permission for an inspection in my absence. (I plan to be there in person when the inspection takes place)

Cost Agreement for septic system installed prior to 1974 and/or used year-round:

Yes, I understand that the GPA will pay for 100% of the inspection costs.

Cost Agreement for septic system installed between 1974 and 1995 and/or for a camp rented out:

Yes, I understand the GPA will pay for 50% of the inspection costs.

Yes, I agree to pay my 50% share of the inspection costs and will make full payment on or before delivery of the inspection report.

Cost Agreement for septic system installed after 1995:

Yes, I'd like the GPA's help in scheduling and coordinating the inspection, most likely along with an inspection of other systems.