Email: All fields on this form are required. * Name: * Territory Address: * Unit & Lot #: * Territory Phone Number: * Permanent Address: * City: State & Zip: Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming * Home Phone: * Year House was built: * Date of last known septic tank inspection/pumping: * Do you want the GTA staff to select the contractor and schedule the work?: No Yes Your septic system will be scheduled for service every four (4) years. If you selected GTA to schedule the work, the contractor selected to do the work will set a specific date with you to perform the work. You will be billed directly by the contractor for the work. If you check no, you do not want GTA to schedule the work you will be sent a postcard reminder when it is time to schedule the inspection/pumping work for your septic system. When the work has been completed we ask that you forward a copy of the inspection report to the GTA office so that we can update your house file. * Owner Signature:
	This site was last updated on 5/17/2012 2:06 PM Copyright Galena Territory Association. All rights reserved.