RILEY COUNTY PLANNING & DEVELOPMENT
110 Courthouse Plaza
Manhattan, KS 66502
(785) 537-6332, ext. 7505
APPLICATION FOR ENVIRONMENTAL EVALUATION
Existing Water Supply
Property address: ____________________________________________________________________________
(Street) (City) (Zip)
Leg
al Description
(copy may be attached):__________________________________________________ Lot size:__________
Di
rections to property
: ___________________________________________________________________________________
Na
me of Purchaser: _________________________________________________________ Phone: ______________________
Mailing Address of Purchaser: ________________________________________________ Phone: ______________________
Name of Purchaser Agent: ___________________________________________________ Phone: ______________________
Name of Seller: ____________________________________________________________ Phone: ______________________
Mailing Address of Seller: ___________________________________________________ Phone: ______________________
Name of Seller’s Agent: _____________________________________________________ Phone: ______________________
Closing Date: _______________ Email Address: _____________________________________________________________
WAT
ER SUPPLY INFORMATION
If public, provide name of system: __________________________________________________________________________
If private, complete the following:
1. Is a well (water supply) contained within the property?
2. Date of construction: ______________________ Permit # _____________________
3. Type of Well Pump:
4. Is there a water softener in the system?
5. Has the system been repaired?
Date and nature of repair: ______________________________________________________________________________
6. Has the structure been treated to prevent or eliminate termites?
WAS
TEWATER DISPOSAL INFORMATION
If public, provide name of system: __________________________________________________________________________
If private, complete the following:
1. Date of installation: _____________ Permit Number: _________________
2. Type of System: Other
3. Laundry wastewater is discharged to: _____________________________________________________________________
4. Date tank was last pumped: ________________________ (Attach copy of pumping report)
5. Is the house occupied? : If no, indicate date of last occupancy:
6. Has the system ever been repaired or modified: If yes, indicate the date and nature of repair/modification:
SELLER’S CERTIFICATION
I, (
Print name) __________________________________, seller of the dwelling at the location described in this application do
hereby certify that the wastewater disposal system is operating satisfactorily and without malfunction at the present time or at
the time when last in use, and that all information provided on this application is true and correct to the best of my knowledge
and belief.
______________________________________________________________________________________________________
(Si
gnature of Seller) (Date)
Y:\Forms\Enviromental\Fillable PDF's
Date (Initial)__________________________
Date (Revisit)________ Date (Revisit)_________
Receipt # ________________
Fees Paid
Initial Visit $100.00 ____________________
Revisit $ 50.00 ____________________
Revisit $ 50.00 ____________________
click to sign
signature
click to edit
![]()
