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    1 views1 page

    Untitled

    Uploaded by

    Candra Kurniawan

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 1

    Lampiran 1: Form 1.

    1 Permohonan Penyedotan Tinja

    DINAS PERUMAHAN DAN KAWASAN PERMUKIMAN KABUPATEN LUMAJANG


    UNIT PELAKSANA TEKNIS DAERAH (UPTD)
    PENGELOLAAN AIR LIMBAH DOMESTIK

    Kepada
    Yth Kepala Dinas Perumahan dan Kawasan
    Permukiman Kabupaten Lumajang

    PERMOHONAN PENYEDOTAN TINJA

    Yang bertandatangan di bawah ini:

    Nama : ………………………………………………………………………………………………………………………
    Alamat : ………………………………………………………………………………………………………………………
    ………………………………………………………………………………………………………………………
    ………………………………………………………………………………………………………………………
    ………………………………………………………………………………………………………………………
    Telpon : ………………………………………………………………………………………………………………………

    Dengan ini mengajukan permohonan pelayanan penyedotan tinja/kakus di:

    Alamat : ………………………………………………………………………………………………………………………
    ………………………………………………………………………………………………………………………
    ………………………………………………………………………………………………………………………

    Keterangan : ………………………………………………………………………………………………………………………

    Kami bersedia membayar retribusi penyedotan kakus sebagaimana ketentuan yang berlaku.

    Demikian permohonan kami untuk dapat perhatian seperlunya.

    Lumajang, 2020

    Pemohon

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