BEFORE ME, the undersigned authority, on this day personally appeared ________________________, who, after

being duly sworn, upon oath states that he/she is the owner of record of that certain tract or parcel of land lying and being situated in Orange County, Texas, and being more particularly described as follows:

The undersigned states that a surface application On-Site Wastewater Treatment System will be/has been installed in accordance with the permitting provisions of the Orange County Health Department. The undersigned has entered into a maintenance contract, as required by the permitting entity, with an approved maintenance company for service and repairs to the surface application system.

The undersigned understands that the State of Texas regulations require that the owner of a Class I Aerobic Treatment Plant with surface application must have an inspection/service contract with an approved maintenance company which must either remain in effect for the life of the system, until the State of Texas regulations change or the building at this location is connected to an organized sewer collection system.

The undersigned understands that disinfection of the effluent from this treatment system is required for all surface application system and he/she willingly undertakes the cost and responsibility.

Further, the undersigned states that he/she will, upon any sale or transfer of the above-described property, request a transfer of the permit to operate such surface application system to the buyer or transferee. Any buyer or transferee is hereby notified that a maintenance contract with an approved maintenance company and a new affidavit filled with the County Clerk will be required for the continued use of the system. A certified copy of the affidavit and a copy of said contract must be sent to the local permitting authority. Failure to properly maintain this system and/or failure to maintain a continual maintenance contract with an approved maintenance company can result in termination of the license to operate this system. For more information concerning the rules

or regulations on surface application by on-site wastewater treatment systems, please contact the Orange County Health Department, 10984 FM 1442, Orange Texas 77630, (409)-745-1463.

WITNESS MY/OUR HAND (S) on this ______day of ______________,2001.

Name (s) of Homeowner (s)

SWORN TO AND SUBSCRIBED BEFORE ME on this_______day of________________, 2001.

(Seal/Stamp) Commission Expires_____________________________