Plumbing Permit Application

PLUMBING APPLICATION HHE-211                                                                               Maine CDC Drinking Water Program / Subsurface Wastewater

                       PROPERTY ADDRESS                                                                        ISSUING MUNICIPAL OFFICE
Street / Subdivision Lot #                                                                   Town / City

PROPERTY OWNER INFORMATION                                                       Permit #                                   Total Fee         $

Name (Last, First)                                                                  Date Issued                                     Double Fee

Applicant Name (Last, First)

OWNER/APPLICANT CONTACT INFORMATION                                                          Local Plumbing Inspector Signature                            License #

Street                                                                                                           State     $                        Local       $
                                                                                            FEES
  City                                                                                           LOCATION                Map #                      Lot #

 State              Zip Code                         Phone
                                                                                             Internal plumbing fixtures and piping may not be installed until a permit is
Email                                                                                       issued by the Local Plumbing Inspector. The permit authorizes the owner
                                                                                                  or installer to install the plumbing system in accordance with this
                   OWNER/APPLICANT STATEMENT                                                    application and the Maine Subsurface Wastewater Disposal Rules.

CAUTION: INSPECTION REQUIRED

I certify that the information submitted is correct to the best of my knowledge I have inspected the installation authorized above and found it to be in and understand that any falsification is reason for the Local Plumbing compliance with the Maine Plumbing Rules Application. Inspector(s) to deny a permit.

Signature of Owner/Applicant                                Date                                    LPI Signature                                 Date (Rough-In)

Copy:        Property Owner                Town               State
                                                                                                                          Date (Final)

                                                            PERMIT INFORMATION
This application is for:                         Type of structure to be served:                                 Plumbing to be installed by:

New Plumbing                          Single Family Residence                             Master Plumber               License #

Relocated Plumbing                           Modular or Mobile Home                          Mfd. Housing Rep.                License #

HUD Homes (permanent frame)                                Multiple Family Dwelling                           Property Owner

Certified Modular Home                             Other (specify below)

 Column 1 – Hook-Up & Relocation                             Column 2 – Fixtures                            Column 3 – Fixtures
                                                                                                                                                      State of Maine
           Maximum 1 Hook-Up                              Type of Fixture                 Qty             Type of Fixture                Qty
                                                                                                                                                Department of Health and
Hook-Up (a)                                         Treatment Softener, Filter, etc.                      Bathtub (and Shower)                      Human Services/
                                                                                                                                                Center for Disease Control
Hook-up to public sewer in those cases                            Hosebib/Sillcock                           Shower (Separate)                       and Prevention
where the connection is not regulated and
inspected by the local sanitary district.                               Floor Drain                                              Sink                Environmental &
                                                                                                                                                    Community Health ●
                                                                             Urinal                                  Wash Basin                  Drinking Water Program ●
                                                                                                                                                  Subsurface Wastewater
Hook-Up (b)                                                      Drinking Fountain                          Water Closet (Toilet)
                                                                                                                                                        286 Water Street
Hook-up to a newly permitted or existing                            Indirect Waste                                Clothes Washer                     State House Station 11
subsurface wastewater disposal system.                                                                                                                Augusta, ME 04333
                                                              Grease/Oil Separator                                   Dishwasher
                                                                                                                                                          207-287-2070
Piping Relocation                                                       Roof Drain                            Garbage Disposal
                                                                                                                                                           HHE-211
Relocation of sanitary lines, drains, and                                     Bidet                                  Laundry Tub
piping without new fixtures within the                                                                                                                 Revised 3/7/2024
structure.                                          Other:                                                          Water Heater

                                                                                                                                                 Enter Total Fixtures /
Total Column 1                   +                         Total Column 2                     +            Total Column 3                 =      Hook-Ups Below

Total Fixtures / Hook-Ups

PERMIT TRANSFER ONLY                            $10.00                                                     Per-Fixture Fee       $

TOTAL PERMIT FEE                $