Dutchess County, NY · Dutchess County
Certification of Fill for Sewage Disposal Systems
This form documents fill installation for a sewage disposal system and is completed and submitted by the project engineer to Dutchess County.
At a glance
- Issued by
- City of Dutchess County · Dutchess County, Dutchess County, New York
- Notarization
- Not required: file this form without a notary.
- Official source
- dutchessny.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
The form certifies that a sewage disposal fill pad was installed satisfactorily in conformance with the approved plan. The engineer completes the project information, fill details, and certification, including inspection dates and any deviations from the approved plan. Dutchess County's instructions also allow test result forms, such as HD-184, to be attached.
Who needs it
An engineer completing and certifying fill installation for a sewage disposal system submits this form to Dutchess County.
How to submit it
Complete Sections A through D and submit the form to the Dutchess County Department of Behavioral & Community Health, Environmental Health Services Division, at 85 Civic Center Plaza, Suite 106, Poughkeepsie, NY 12601.
About notarization
This document is signed and dated without a notary; the form asks the engineer to sign and provide a license number and seal.
How to submit this form
- 1
Download the Form
Download the Certification of Fill for Sewage Disposal Systems PDF.
- 2
Complete the Sections
The engineer completes Sections A through D with project details, fill information, and certification.
- 3
Gather Attachments
Attach test result forms, such as HD-184, if applicable. List and justify deviations from the approved plan on the back.
- 4
Submit to the County
Submit the completed form to the Dutchess County Department of Behavioral & Community Health at the address printed on the form.
Frequently asked questions
- Do I need a notary for the Certification of Fill for Sewage Disposal Systems?
- No. The form has no notary block; the engineer signs and dates it and provides a license number and seal.
- Who completes this certification form?
- The form instructions direct the engineer to complete Sections A through D and submit the form to the Dutchess County Department of Behavioral & Community Health.
- How do I submit the Certification of Fill?
- Submit the completed form to the Dutchess County Department of Behavioral & Community Health, Environmental Health Services Division, at the address printed on the form.
- What information does the form request?
- It requests project and lot details, permeable and impervious fill information, and the engineer's certification, inspection dates, signature, license number, and seal.