Property ID____________________________________________
New Renewal Redesign Alteration Revision Repair Waiver request
Applicant _____________________________________________
Mailing Address________________________________________ City __________ Zip___________
Installation Address_____________________________________ City __________ Zip_____________
Sec _____ Twp _____ Rg ____ 1/ 4Sec _____ Subdivision Name ______________________ lot _____ Blk _____
Water Supply: Individual well Public System Name ____________________________
_______________________________Onsite Sewage System Design Information____________________________________
Attach 2 copies of the onsite plans with a minimum of 5 soil log descriptions
Type of Building: New Existing SFR Duplex ____# of Bedrooms Commercial Other _______
Pretreatment Type: _______ SF ______ ATU _______ PSF ________Other N/A
Dispersal Type: Gravity LPD SSD Mound SLB Other ________
Lot Size ________ Operating Capacity ________ gallons/day Design Flow ________ gallons/day
Depth to Water table / Restrictive layer _______ Soil Type (1-6) ______ Application Rate ______gallons /sq ft. /day
Absorption Area _____ sq ft. Installation Depth ______ inches Date Soils logged ______
Septic Tank Size ______gallons Pump Chamber Size ______gallons Required Soil volume _______cu/yd.
Signature of Designer _______________________ Date ___________ Address_________________________
Designer Name ____________________________ License # ____________ Phone ______________________
Owner or Authorized Agent____________________________ Signature _______________________________
Printed name
_________________________________________FOR DEPARMENTAL USE ONLY_______________________________________________
Application Approved ___________ Sanitarian _______________________________ Date __________________
Comments Attached ________________________________________________________________________________________________
Application Expires ON _________________ Approval of this application does not constitute a permit to begin construction and installation
of the system or any other improvements on the site. This approval shall not be considered an assurance that development permits for this
site will be issued. An appeal process of a denial of this application will be furnished on request. Soils in the designated Drainfield and
reserve should remain undisturbed. _________ Owner or authorized agents initials.
Permit Issued #_______________ FEE(s) $
__________________________ Sanitarian ___________ Date _______
Final Inspection___________ Final Inspection Approved____________
click to sign
click to edit
click to sign
click to edit