WORK ORDER FORM Wieser Septic

WORK ORDER FORM

A Division of; Jake Wieser Construction, Inc. LIC #L2929 507-895-8213
TYPE OF WORK (SELECT ALL THAT APPLY)
TYPE OF WORK*

Septic InspectionWell InspectionSeptic InstallationSeptic DesignSewer ConsultationWater TestExcavationDemolitionCity/Sewer/Water
WATER TEST TYPE*

NitrateLeadRadonBacteria/EcoliArsenicNitrite
PROPERTY OWNERS:
Name *

First NameLast Name
SITE ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MAILING ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
TELEPHONE*
Cell*
Email*
example@example.com
DIRECTIONS
HOUSE INFORMATION NEEDED FOR SEWER INSPECTION AND SEWER DESIGN:
DATE EXISTING SYSTEM WAS CONSTRUCTED (IF APPLYS)

MonthDayYear
Date
REASON FOR WORK*
NUMBER OF BEDROOMS*
NUMBER OF BATHROOMS*
DISHWASHER*
Please Enter YES or NO
GARBAGE DISPOSAL YES OR NO*
SEWAGE PUMPED TO TANK YES OR NO*
HAS THERE EVER BEEN ANY PAST LEACHING OF SEWAGE TO THE SURFACE OF THE GROUND (YES OR NO)*
I have read and agreed to all the terms in the On-Site Wastewater Treatment System Inspection and or Design Agreement. Payment for the above services will be paid by:
(Check one and fill out accordingly)*

CheckCredit/Debit Card
COMPANY AND AGENT ORDERING THE INSPECTION:
COMPANY
AGENT
TELEPHONE #'s
FAX
EMAIL
example@example.com
DATE ORDERED

MonthDayYear
Date
TIME ORDERED
REQUESTED COMPLETION DATE*

MonthDayYear
Date
SIGNATURE*

Clear
PRINTED NAME*
Should be Empty: