MARICOPA COUNTY ENVIRONMENTAL SERVICE DEPARTMENT
WATER & WASTE MANAGEMENT DIVISION
ONSITE WASTEWATER SYSTEMS PROGRAM
501 North 44th Street, Suite 200, Phoenix, AZ 85008
Phone: (602) 506-6666 Fax: (602) 506-6925
Email: SepticQuestions@maricopa.gov Website: esd.maricopa.gov
July 2019
REQUEST FOR
TO OPERATE A TYPE 4 ON-SITE WASTEWATER TREATMENT
FACILITY UNDER GENERAL AQUIFER PROTECTION PERMIT 4.02-4.23
Owner Information: Permit Number
Name: ____________________________________________________ ___________
Site Address: _____________________________________________
_____________________________________________
Agent:
Name: _____________________________________________________
Mailing Address: _____________________________________________
_____________________________________________
Phone: _________________ Fax: _________________ E-Mail: _______________________
On-Site Installer: Installer’s License #
Name: _____________________________________________________ _________________
Mailing Address: _____________________________________________
_____________________________________________
Phone: _________________ Fax: _________________ E-Mail: _______________________
Construction shall conform to the approved plans. This on-site wastewater system was built in accordance to (check one):
□
□
□
□
Manufacturer: ________________________________ Model Name/Number: __________________ Capacity: _________
□
Certification: Owner/Agent/Installer (circle one)
I _____________________________________, certify that this Notice for Discharge Authorization and all attachments were
prepared under my direction or authorization and all information is, to the best of my knowledge, true, accurate and complete. I
also certify that the septic tank described on this form is constructed and installed per the Arizona Administrative Code Title 18,
Chapter 9, the Maricopa County Environmental Health Code and with applicable requirements of A.R.S. Title 49, Chapter 2. I
am aware that there are significant penalties for submitting false information, including permit revocation and the possibility of
fine and imprisonment for known violations.
Signat
ure _____________________________________________ Date ___________________________________
Special Instructions: _____________________________________________________________________________________
_____________________________________________________________________________________
The original site plan submitted with the Notice of Intent to Discharge accurately reflects final location and configuration
A final as-built site plan showing the final location and configuration of components has been submitted and approved. All
fees for the revision review have been paid.
Engineered/Alternative Wastewater Treatment System: As-built plans and operational verification letter, Certificate of
Completion, O & M Plans and other information required under A.A.C. R18-9-A309(C)(2) for review and acceptance by
the department have been submitted.
The tank has been installed in accordance with the manufacturer’s instructions and certified to conform to the
requirements of R18-9-A314.
The tank has passed a water tightness test [R18-9-A309(C)(1)]
TO INITIATE THE FINAL INSPECTION, CALL THE INSPECTION LINE AT 602-506-1787. COMPLETE THE REQUEST FORM THAT IS
INCLUDED WITH THE CONSTRUCTION AUTHORIZATION. SUBMIT THE REQUEST FORM TO THE ONSITE WASTEWATER
TREATMENT PROGRAM IN PERSON, EMAIL SepticQuestions@maricopa.gov , ON-LINE
http://esd.maricopa.gov/FormCenter/Environmental-Services-16/Onsite-Wastewater-Systems-Program-Inspec-90 OR FAX TO
602-506-6925.
click to sign
signature
click to edit
![]()
