FAX WORK REQUEST FORM - HOLLER ENGINEERING

Date:_________________ Proposed closing date: ______________________________________

From : Agent ____________________ Office ______________________ Ph# _______________

Legal Description: Legal description _________________________________________________

Client/responsible party: __Owner/seller __Buyer __Contractor __Other _____________________

Closer/Paperwork goes to:_______________________Type of financing:____________________

Owner/seller_______________________________ Buyer________________________________

Address __________________________________ Address_______________________________

Address __________________________________ Address_______________________________

Ph # _____________________________________ Ph # _________________________________

House: __Vacant __Occupied, for access call__________________________________________

Work Requested: __Well/septic test Package __WFT/Bacteria sample __Septic Test only

__Engineer’s Letter __Survey/asbuilt(if a recert, original surveyor_________________________)

Other _____________________________________________________________

Septic: __Onsite __Public/comm. __Lift station. System Approved/documented? __yes __no

Water: __Private __Public/comm. Water softener or water filter installed? __yes __no

Well log available? __yes __no; approx.depth/flow is:____________________________________

Additional Notes:_______________________________________________________________

Authorization: I authorize Holler Engineering to complete the described work in accordance with their standard fee schedule:

Print name_______________________________(sign) __________________________________

--- Please fax completed form to (907) 376-0410 ----