I _______________________________________ being the owner/authorized agent of property known

(Printed Name)

as ___________________________________________________________________ request a waiver from

(Address of building project) (Township)

Environmental Health Division Review of my proposed building project, which will consist of _______________

_______________________________________________________________________________________________________________.

By making this waiver request I take full responsibility for any problems that occur as the result of the above referenced construction with regard to the well and septic system on this property. As a condition of receiving this waiver I agree that all of the following statements are true:

˜ This project will not involve the installation of any new bedrooms or any type of plumbing.

˜ This project will occur on a parcel greater than 2.0 acres in size.

˜ This project will not involve construction activities within 15 feet of the septic tanks or drainfield.

˜ This project will not involve construction activities within 5 feet of the well.

˜ This project will not involve changing more than 50% of the existing home.

˜ I have located my septic system and take full responsibility if the construction encroaches on these systems.

I understand that if this construction project encroaches on the existing septic system, existing well, or future areas for well and septic system the structure may be required to be demolished.

I understand that if the existing well or septic system is encroached or damaged that my building permit will be revoked.

_________________________________ ____________________

Signature Date

_________________________________ ____________________

Witnessed by: Washtenaw County CSR Date