TOWN OF QUARTZSITE
P.O. Box 2812 465 N. Plymouth Avenue Quartzsite, AZ 85346
928-927-4414 FAX 928-927-4400
Sewer Connection
APN# ___________________________ Utility Acct. #________________
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Owne(Last)_____________________________ (First) _________________________________
Mailing Address ____________________________________________________________
City ___________________________ State _______ Zip ________
Telephone(_____)______________
Commercial Business Name __________________________________________________
Site Address ______________________________________________________________
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Contractor ____________________________________ License No___________________
Address_______________________ City________________ State ______ Zip _________
Telephone (_____)_________________
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One Stub/other
[ ] I certify I am currently licensed under the provisions of the Arizona Registrar of
Contractors for this work.
[ ] I am the owner of this property and I am doing my own work.
[ ] I am exempt from the provisions of the Arizona Registrar of Contractor’s regulations.
Existing Septic Tanks MUST be abated
(Town Code Section 16-1-4, Paragraph B)
for final inspection by the Town Building Inspector.
***Inspections are required prior to concealment.****
Signature _______________________________________________Date _____________________________
Receipt Number ______________ Amount ____________ Date _____________ Rec’d By ___________
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