EOH Septic System Rehabilitation Reimbursement Application

Application for Reimbursement

If you are not able to complete the required fields or have any question about the information that is needed, contact the EOH staff at eohseptic@dep.nyc.gov or 914-739-5404. To apply for reimbursement for multiple contractors, please submit a separate application for each contractor.

For more information, visit East of Hudson Septic System Rehabilitation Reimbursement Program.

* Indicates required fields

Name*

Email*

Phone*

Property Address*

Contractor Information

Name of Contractor*

Service Provided*

Date of Service (Format: mm-dd-yyyy)*

Type of Payment*

Payment Amount*

Please upload Proof of Payment * Choose a file…no file selected

Please upload Invoice Receipt * Choose a file…no file selected

Other Required Documents

Please upload County Health Department Permit - Signed and dated * Choose a file…no file selected

Please upload As-built drawings and/or contractors sketch * Choose a file…no file selected

Please upload County Health department final site inspection report * Choose a file…no file selected

Notes or comments about this application

I hereby certify under penalty of perjury that the above statements are true and correct, that I am the owner of the above referenced system, and that I have not received reimbursement for the above listed Items or services from any other source. I understand that any false statement may disqualify me from reimbursement under the East of Hudson Septic System Rehabilitation Reimbursement Program.*

I certify

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