ࡱ> Z\Y!` wbjbj\\ =>>\ ,,,@$ $ $ 8\ p @ ( OQQQQQQ$hu,"u 1v8 , OO, LN~$ ;0~ ~~,,uu^@@@$ @@@$ @@@  STATEMENT OF COMPLIANCE FOR eNGINEERED SYSTEM INSTALLATION The design engineer shall provide the LPI, the owner and DHHS with a copy of this completed document or an equivalent written statement. The design engineer should retain a copy. I, (please print), am the design engineer for the engineered subsurface wastewater disposal system located at (street and town/city) __________________________________________ ____________________________________________________________________________________________________ . The property owners name is: _______________________________________. The permit number is: . [ ] I [ ] my representative(s) (check both if appropriate), according to the fb88 Subsurface Wastewater Disposal Rules; the Subsurface Waste Water Disposal System Application, e.g., the HHE-200 form; and plans stamped and signed by ________________________________P.E. license number_______ observed that the system was installed in compliance with the Rules and the conditions of approval. Any as-built changes from the approved drawings and specifications are attached. Signature of design engineer: P.E. license number _________________ Date signed: / / mm dd yy Imprint License Stamp Above     Page  PAGE 4 HHE-220 02/2004 Page  PAGE 1 of 1 HHE-220-a 02/2004  ?@A|}   p u y | ! ' 0 \ ] _ ` b c e f h l q r x y z { E訠訠h;0JCJmHnHuhY#0JCJmHnHuhY#0JCJjhY#0JCJUhjhUhY#OJQJhY#CJOJQJhY#6CJ] hB CJ hY#>*CJ hY#CJhY#jhU_UmHnHu2 ?@A _ | } \ ] ! 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