Helping Hands Across Alabama
Onsite Septic System Application
NAME:
NAME OF SPOUSE:
MOBILE PHONE:
HOME PHONE:
EMAIL ADDRESS:
, Alabama
ZIP CODE:
PLEASE SELECT ONE:
HOW MANY PEOPLE CURRENTLY LIVE IN THE HOME?
DO ANY DISABLED INDIVIDUALS LIVE IN THE HOME?
HOW MANY?
COUNTY HEALTH DEPARTMENT JURISDICTION:
ADDRESS:
TOTAL ANNUAL HOUSEHOLD INCOME:
CITY:
DO YOU OWN THIS HOME? 
IF YES, HOW MUCH DO YOU OWE?
IF NO, WHO IS THE CURRENT PROPERTY OWNER?
PLEASE LIST ANY GOVERNMENT ASSISTANCE RECEIVED:
ARE YOU A VETERAN?
TYPE OF SYSTEM NEEDED:
INDIVIDUAL/COMPANY RECOMMENDING SYSTEM OR REPAIR NEEDED:
PHONE NUMBER:
EMAIL ADDRESS:
PERSON REQUESTING SYSTEM SIGNATURE:
DATE:
HOUSEMOBILE HOME
YESNO
YESNO
YESNO