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Building ● Economic Development ● Environmental Quality/Waste Disposal ●
Flood Control ● Planning ● Zoning
MOHAVE COUNTY
DEVELOPMENT SERVICES
P. O. Box 7000 Kingman, Arizona 86402-7000 3250 E. Kino Ave, Kingman www.mohavecounty.us Telephone (928) 757-0903 FAX (928) 757-3577
Timothy M. Walsh, Jr., P.E.
Sam Elters, P.E.
Department Director
County Manager
The following must be submitted in order to complete an application for the above-referenced facility
type(s).
Please submit in the following order:
1. Mohave County Permit Application Worksheet
2. Notice of Intent to Discharge
3. Site Investigation Report (original copy)
4. Design Configuration Sheet
5. Sewer Availability Sheet
6. Temporary Agreement (Bullhead City and Mohave Valley only)
7. List of Materials, Components and Equipment for constructing the on-site wastewater facility
8. Draft Operation and Maintenance Manual
9. On-site Wastewater Facility Site Plan (2 copies)
***USE ENGINEER’S SCALE – MAX. 1”=40’
The application will be reviewed by the appropriate district office. If the application is complete and all
requirements have been met, a Construction Authorization will be issued to the applicant.
Construction may begin of the on-site wastewater facility. When construction is completed, a Request for
Discharge Authorization must be submitted to the appropriate district office requesting an inspection of the
facility. The following must be submitted with this form:
1. Final as-built site plan of the project, if it differs from the proposed plan.
2. Certification that the septic tank passed the required watertightness test in the field, after
installation.
When the above documents are received, the district office will perform a final inspection of the facility. If
the facility was constructed according the approved plan and is in compliance with all applicable State laws
and local regulations, a Discharge Authorization will be issued.
Notes:
1. Construction of the facility CANNOT take place until the Construction Authorization is issued.
2. Discharge CANNOT take place until the Discharge Authorization is issued.
3. If the construction differs from the proposed plan, and a second inspection and/or second review of
the system is necessary, additional fees will apply.
4. If you are submitting to the Bullhead City District office, you must complete a Sewer Availability
Information Sheet from the sewer provider for your property location. This MUST be done PRIOR
to having a site investigation and must be attached to the application submittal.
PROCEDURES TO OBTAIN DISCHARGE
AUTHORIZATION
FOR AN ONSITE WASTEWATER TREATMENT FACILITY
TYPE 4.02 GENERAL PERMIT
CO
N
VENTIONAL SYSTEM
Building ● Economic Development ●
Environmental Quality/Waste Disposal ● Flood Control ● Planning ● Zoning
MOHAVE COUNTY
DEVELOPMENT SERVICES
P. O. Box 7000 Kin
gman, Arizona 86402-7000 3250 E. Kino Ave, Kingman www.mohavecounty.us Telephone (928) 757-0903 FAX (928) 757-3577
Timothy M. Walsh, Jr., P.E.
Department Director
Sam Elters, P.E.
County Manager
INSTRUCTIONS
Please fill out and submit this Notice of Intent to Discharge (NOI) to obtain authorization to construct and operate a septic tank and
disposal field under a Type 4.02 General Aquifer Protection Permit in accordance with Arizona Administrative Code (A.A.C.) R18-9-
E302.
GENERAL APPLICATION PROCESS
1. Submit this NOI and appropriate supplemental information and forms, which are identified in this form. Please submit this
application to the appropriate district office listed below:
Bullhead City District Kingman District Lake Havasu City Distri
ct (Drop Box Only)
1130 Hancock Rd. 3250 E. Kino Ave. 2001 College Ave, Suite 95
Bullhead City, AZ 86442 Kingman, AZ 86409 Lake Havasu City, AZ 86403
(928) 758-0704
(928) 757-0903 (928) 757-0903
kgmpermitstaff@mohavecounty.us
2. Review fees
established by the Mohave County Board of Supervisors. The fee is at time of application. Each Request for
“Approval of Alternative Feature of Technology, Design, Setback, Installation, or Operation” submitted with this NOI is
subject to an additional fee. Each resubmittal, additional inspection and/or consultation is subject to an additional fee. If a
system is installed before the “Construction Authorization” is given, an additi
onal fee will be assessed along with possible
legal action.
3. Satisfy any deficiency requests arising from the Department’s pre-construction review of the submitted information.
4. Receive a “Construction Authorization” from the Department authorizing construction of the onsite wastewater system
.
5. Construct the onsite wastewater system within two years.
6. Upon completion of construction, submit a Request for Discharge Authorization and any required information to the
Department to initiate the Department’s post-construction review and inspection. If the applicant has not completed the entire
project as stated in the “Construction Authorization” and is submitting a Request for Discharge Authorization for the portion
completed, the applicant will need to resubmit a NOI for the remaining portion of the project.
7. Satisfy any deficiency request arising from the Department’s post-construction review of the facility.
8. Receive a “Discharge Authorization” from the Department, which authorizes operation of the septic tank and disposal field
in accordance with the terms of the Type 4.02 General Aquifer Protection Permit and applicable requirements of statute and
rule.
LICENSING TIME FRAMES (LTF)
Licensing Time Frames are specified by the Arizona Department of Environmental Quality in AAC R18-1-525, Table 10. They are:
License Type
Administrative
Completeness Review
Substantive Review
(plan review)
Overall Time Frame
Single 4.02, 4.03, 4.13, 4.14, 4.15, 4.16
General Permits
42 days 31 days 73 days
Combined Two or Three Type 4 General
Permits
42 days 53 days 95 days
Combined Four or more Type 4 General
Permits
42 days 94 days 136 days
Name and t
elephone number of a person who can answer questions or provide assistance during the application process: Your
assigned inspector either in person or by phone at the offices and numbers listed above. If you are unable to receive assistance, you
NOTICE OF INTENT TO DISCHARGE FOR A
CONVENTIONAL SEPTIC TANK AND DISPOSAL FIELD
SYSTEM
(Type 4.02 General Aquifer Protection Permit)
Mailing Address: DEPARTMENT NAME P.O. Box 7000, Kingman, AZ 86402-7000
Note: Must provide construction drawings for Development Services application (Residential – 2 complete sets)
Mohave County
Permit Application Worksheet
Residential
Date_______________
Project # _____________
Permit # _____________
PLOT PLANS MUST BE NO LARGER THAN 8 ½ “ X 11”
NOTE: Shaded areas are for county use only.
1. Type of Improvement:
2. Applicant’s name:
Mailing address:
City: State: Zip:
2A. Contact Name: PHONE:
Fax Number: Email:
3. Property Owners Name:
Mailing Address:
City: State: Zip:
Fax Number: Email:
4.
SITE LOCATION ADDRESS:
House No Street Dir Street Name:
5. Legal Description:
Assessor Parcel Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___ Parent Parcel: Yes
Subdivision Name: Corner Lot: Yes
Unit/Tract/Block/Lot: -- -- --
Township/Range/Section: -- --
6. Plot Plan Drawing (see instructions on plot plan form) Cont Acres
Public Works, Flood Control Division
7. Is there an existing structure? YES NO
7A. Previous PFI#: _________________ Previous FUP#: _____________________
FLOOD $____________
Environmental Quality Division
8. Is this an existi
ng system?
YES NO
8A. Is this a Conventional Septic?
YES NO, Alternative System? YES NO
9. Septic Tank Size:
Manufacturer: _________________________________
10. Septic Contractor:
License #: ________________________
Or Owner / Builder:
YES NO
11. Water Source: __________________________
Number of bedrooms:___________
Number of fixture units:_________
Planning & Zoning Division
12. Zoning: _________________________
13.
Mobile Home or Recreational Vehicle Information:
Make:
Size: of beds: Year: ______________
State #:
HUD or VIN: __________________________________________
Mobile Home Installer Name: ____________
_________________________________________
License #:
Address: ____________________________________________
Phone: _______________________________
14. Water Source: _________________________
15. Sanitation:
Sewer Septic [Septic Permit #: ]
16. Contractor Information (Names & License #’s)
- General Contractor:
License #:___________________
- Electrical Contractor:
License #:___________________
- Plumbing Contractor:
License #:___________________
- Mechanical Contractor:
License #:___________________
17. GRADING PERMIT: Material amount (cubic yards)? __________________________________
18. Bond Exemption:______________________________
ZONING $_____________
BLDG $_____________
P/C $_____________
AUTOMATION
FEE $_____________
OTHER $_____________
BAL DUE $_____________
SUBTOTAL $_________
DEPOSIT <$__________>
0
0
0
0
0
Building ● Economic Development ● Environmental Quality/Waste Disposal
● Flood Control ● Planning ● Zoning
may contact the Waste Disposal Services Manager at the Kingman office (number listed above).
Under ARS §11-1609, you may request that the County clarify its interpretation or application of a statute, ordinance, regulation,
delegation agreement or authorized substantive policy statement that affects the issuance of your permit by providing the County with
a written request that states: 1. Your name and address; 2. The statute, ordinance, regulation, delegation agreement or authorized
substantive policy statement that requires clarification; 3. Any facts relevant to the requested ruling; 4. Your proposed interpretation
of the applicable statute, ordinance, regulation, delegation agreement or authorized substantive policy statement or part of the statute,
ordinance, regulation, delegation agreement or authorized substantive policy statement that requires clarification; 5. Whether, to the
best of your knowledge, the issues or related issues are being considered by the County in connection with an existing license or
license application.
Nam
e
________________________________________________________
Phone____________________________
Title ________________________________________________________ Firm Nam e_______________________
M
a
iling Address _______________________________________ City __________________________ Zip ______________
4 Contact Person/Agent (if different from applicant)
Name ________________________________________________________ Phone________________________________
Title ________________________________________________________ Firm Name____________________________
Mai
ling Address _______________________________________ City __________________________ Zip _____________
5 Installation Contractor Name and Information
Name ________________________________________________________ Phone_____________________________
License Number
_________________________________________________
Firm Name___________________________
M
ailing Address _______________________________________ City __________________________ Zip ___________
6 Site Information
County City_____________________________________________
Location of downstream end of system proposed herein
Township ______________ Range ___________ Section _________,
Latitude ____________° ___________’ ___________”N ______ Longitude ___________° ___________’ __________”W
Legal Description of Propert
y
_________________________________________________________________________________
7 Existing Environmental Permits
List any other federal or
state environmental permits issued for or needed by the facility, including any individual permit,
Groundwater Quality Protection Permit, or Notice of Disposal that may have previously authorized discharge (attach additional
pages if necessary)___________________________________________________________________________
SUPPLEMENTAL INFORMATION
8 Information and Submission Requirements (Check All Completed Items – attach to application)
Site Investigation Report (original) per A.A.C. R18-9-A309(B)(1)
Site Plan and construction quality drawings of the system per A.A.C. R18-9-A309(B)(2) and (6)(a)
Operation and Maintenance Manual per A.A.C. R18-9-A309(B)(6)(b), A313(B) and A309(C)(2)(c)
List of Materials, Components and Equipment per A.A.C. R18-9-A301(B) and A309(C)(2)(b)
Agency review fee (see instructions)
GENERAL INFORMATION
1 Project Name:_______________________________________________________________________________
2 Owner/Operator (person responsible for overall compliance)
Name ________________________________________________________ Phone_______________________________
Title ________________________________________________________
Firm Nam e__________________
_________
Mailing Address ______________________________________ City __________________________ Zip ______________
3 Applicant
NOTICE OF INTENT TO DISCHARGE FOR A
CONVENTIONAL SEPTIC TANK AND DISPOSAL
FIELD SYSTEM
(
T
ype
4
.0
2
Ge
n
e
r
a
l A
qu
if
e
r Pr
otect
i
o
n P
e
rmi
t)
____________________________________
Building ● Economic Development ● Environmental
Quality/Waste Disposal ● Flood Control ● Planning ● Zoning
9 Project Description (Check One)
Conventional Septic System Serving a Single-Family Residence
Conventional Septic System Serving Other Than a Single-Family Residence
10 Septic Tank and Disposal Field Description
This on-site wastewat
er treatment facility consists of an conventional septic tank system and disposal field sized for a
design flow of __________gallons per day. The flow is based on number of bedrooms and/or fixture units:
Number of Bedrooms __________ Number of Fixture Units _________
Floor plan included in this application packet
The septic tank conveys wastewater to a disposal field consisting of (check one):
Trench
Filled with aggregate [R18-9-101(1)], or
Filled with crushed, recycled concrete [R18-9-E302(C)(2)(d)]
Bed
Chamber Technology
Seepage Pit
The expected date of first operation of this system is: _________________________________________________________
The sewage to the septic tank has the characteristics of:
Typical household sewage, or
Typical household sewage and _________________________________________________________________________
_______________________________________________________(list other sources and characteristics of the wastewater)
Site Investigation Information
Percolation Test Conducted Rate:_________mpi
Soils Testing Conducted
Soil Absorption Rate (assigned by Site Investigator): _________ gpd/sq. ft
11 Other Miscellaneous Required Information
Water Supply (check one):
Public Water
Private Well
If no public water is available, and system is located less than 50 ft. from any property line, applicant must obtain an
agreement from the owners of any affected undeveloped adjacent property to limit the location of any new well on their
property to at least 100 feet from the proposed treatment works and primary and reserve disposal works. The
agreement must be recorded appropriately and the documentation must be approved by the Department.
Letter included in this application packet
Haul Water
Comment same as above
Letter included in this application packet
Wash or drainage easement
If system is proposed within the 50 foot setback required by the Aquifer Protection Permits, a letter must be obtained from the
appropriate flood plain administrator allowing a reduction of the setback.
If applicable, letter from floodplain administrator included in this application packet
13 Certification of Compliance (To be completed by the applicant in item 3 above)
I,_________________________________, certify that this Notice of Intent to Discharge 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 and disposal field system described in this form is or will be designed, constructed, and operated in accordance with the terms
and conditions of a Type 4.02 General Aquifer Protection Permit (AAC R18-9-E302) and applicable requirements of Arizona Revised
Statutes Title 49, Chapter 2, and Arizona Administrative code Title 18, Chapter 9 regarding aquifer protection permits. I am aware
that there are significant penalties for submitting false information including permit revocation as well as the possibility of fine and
imprisonment for knowing violations.
_____________________________________________________________________
Signature
___________________________________
Date
DEPARTMENT USE ONLY
DATE STAMP
File Number
Fee Paid for this Project
Check Total
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DISPOSAL FIELD DESIGN/CONFIGURATION
Shallow trench, Bed or Chamber Cross-section
PROJECTED SEWAGE FLOW: ____________ g.p.d. SOIL ABSORBTION RATE (SAR): ___________________
ABSORPTION AREA: ____________________
DisposalDesign: 11-16-05
Shallow/Deep Trench Configuration (circle one)
Please indicate vertical depths using inches.
A. Backfill to final grade ……….. __________
A-1 [Graded soil area, state using a (-) sign] ___________
A-2 [Fill or topsoil, state using a (+) sign] ____________
B. Distribution pipe w/ 2” of rock __________
C. Aggregate depth (effective depth) __________
D. Total trench depth __________
(Shallow trench is 60” or less total depth)
Trench width __________
Total length of trench __________ (ft.)
Original Grade
Final grade
A
D
B
C
Width
Gravity Beds
A. Backfill __________
B. Distribution line with 2” of aggregate material ______
Finish grade
A
C. Aggregate depth __________
D. Total Bed depth __________
(Gravity Bed shall be less than 5’ total depth)
Trench width 10’ or 12’ (circle one)
Distance between pipes 4’ or 6’ (circle one)
Total length of Bed __________
B D
C
10’ or 12’
Chamber Technology
Manufacturer ______________________________________
Model # __________________________________________
Width of the open bottom absorption surface of chamber: _________________
Vertical height of the chamber side wall ______________
Length of the chamber ____________
Chamber Area = (1.8 x W x L) + (2 x V x L)
Number of Chambers: ________________
Length of disposal field: ________________
SitePlanForm: 11-16-05
ON-SITE WASTEWATER SYSTEM
SITE PLAN
(for 4.02 General Permit only. 4.03-4.22 must provide construction quality drawings)
Address: North Arrow shown
Assessor Parcel: Boundaries of property shown on plan
Proposed/existing systems, dwellings, buildings, driveways, swimming pools, tennis
courts, wells, ponds, and any paved, concrete or water feature, shown.
Slopes and cut banks greater than 15%, retaining walls and other constructed features shown
Any feature less than 200 ft. from facility and reserve area that constrains the location due to
setback limitations shown
Legal Description:
Topography shown with contour intervals, showing orig
inal and post-installation grades
Property Size (in acres): EXACT LOCATION of all soils testing and percolation sites
Engineer’s Scale (max 1”=60’): Location of the treatment and disposal works, pipelines, reserve area
Permit Number: Location of any public sewer if less than 400 ft. from property line
Proper construction and installation of this system shall follow all applicable Federal, State, County and City laws. Mohave county disclaims any
responsibility of the construction, installation, errors or omissions involved with this system and the sole responsibility for any of the above is with the
owner or his/her contractor (s) and/or agents (s). The as-built drawing is provided for ease and convenience to locate the system in the future and not for
construction purposes.
The information within the site plan submitted is true and accurate to the best of my knowledge;
___________________________________________________________________________________________ Date: ___________________
Signature Title
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FIXTURE COUNT CALCULATION CHART
Use the fixture count chart below to determine the total number of fixture units in the home. Check the
corresponding box on the system design flow chart based on your fixture count or number of
bedrooms whichever is greater. The box that is checked is the row where you’ll find your minimum tank
size and system design flow. Enter the information at the bottom of the page, and submit this form with your
application.
Residential Fixture
Type
Existing #
Fixtures
Proposed #
Fixtures
Multiply by Fixture Units Equals
Total #
PROPOSED
Fixtures
Bathtub
x
2
=
Bidet
x
2
=
Dishwasher, service
x
2
=
Clothes washer
x
2
=
Utility tub or sink
separate from clothes
washer
x
2
=
Sink, kitchen (with or
without dishwasher
x
2
=
Shower, single staff
x
2
=
Sink, bar
x
1
=
Sink, service
x
3
=
Lavatory, single or
double
x
1
=
*Toilet, 1.6 gallons per
flush (gpf)
x
3
=
*Toilet, 1.6 - 3.2 gpf
x
4
=
*Toilet >3.2 gpf
x
6
=
FIXTURE COUNT TOTAL
=
Physical # Bedrooms
=
*Toilets currently available in Arizona are 1.6 gallons per flush. Older fixtures may not use the same amount of gallons
per flush.
SYSTEM DESIGN FLOW CHART
No. of Bedrooms Fixture Count Minimum Tank Size (gallons)
System Design Flow
(gpd)
1
7 or less
1000
150
More than 7 less than 14
1000
300
2
14 or less
1000
300
More than 14 less than 21
1000
450
3
21 or less
1000
450
More than 21 less than 28
1250
600
4
28 or less
1250
600
More than 28 less than 35
1500
750
5
35 or less
1500
750
More than 35 less than 42
2000
900
6
42 or less
2000
900
More than 42 less than 49
2500
1050
7
49 or less
2500
1050
More than 49 less than 56
3000
1200
8
56 or less
3000
1200
More than 56
3000
1350
NOTE: For a single residence with more than 8 bedrooms, use R18-9-A314 (D) (2) as the basis for determining minimum
septic tank size and system design flow.
FOR RESIDENTIAL USE
P. O. Box 7000 Kingman, Arizona 86402-7000 3250 E. Kino Ave, Kingman www.mohavecounty.us Telephone (928) 757-0903 FAX (928) 757-3577
SEWER AVAILABILITY INFORMATION SHEET
Service Provider/Company Name:
Submitted by:
Telephone:
Fax:
Date:
Name of Property Owner:
Location Address:
Subdivision:
Tract:
Block:
Lot:
Assessor Parcel Number:
Indicate below what type of project will be constructed on the above mentioned property:
Residential (Single Family Only)
Commercial/Multi-family
Estimate flow rate in gallons per day:
Industrial
Estimate flow rate in gallons per day:
Flood Zone:
Applicant Signature:
Per an inquiry with the above-referenced service provider regarding the availability of sanitary sewer
to serve the above-referenced location, sewer is available at property:
Yes, sewer is available and will be connected to
No, sewer connection exceeds fees of R18-9-A309(A)(5)(b) (Engineers/Contractor’s Estimate req.)
N/A, no sewer service provider in area
Distance to sewer: feet
Comments:
Sewer Provider Representative Signature:
MCEQ Revised: 6.19.19
Building ● Economic Development ● Environmental Quality/Waste Disposal ● Flood Control ● Planning ● Zoning
MOHAVE COUNTY
DEVELOPMENT SERVICES
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Building ● Economic Development ● Environmental Quality/Waste Disposal ● Flood Control ● P
lanning ● Zoning
MOHAVE COUNTY
DEVELOPMENT SERVICES
P. O. Box 7000 Kingman, Arizona 86402-7000 3250 E. Kino Ave, Kingman www.mohavecounty.us Telephone (928) 757-0903 FAX (928)757-3577
Ti
mothy M. Walsh, Jr., P.E. Sam Elters, P.E.
Department Director County Manager
To:
SANITARY DISTRICT OR UTILITY COMPANY
TEMPORARY INDIVIDUAL WASTE DISPOSAL SYSTEM
I, , Owner of property located in the
Subdivision, Tract , Block , Lot ,
Address , Arizona, understand that the sewage disposal
system to be installed to service my residence located on the above described property is a temporary
system. I, hereby agree to abandon such system in a method approved by the local
Environmental Quality Department, and connect to municipal sewer system servicing our location
within thirty (30) days after sewer connection is available.
The Mohave County Development Services Department, Environmental Quality/Waste Management
Division located at 1130 Hancock Road, Bullhead City, AZ 86442 (928) 758-0707 is to be notified prior
to abandonment of the system.
TEMPORARY PERMIT # ______________ ASSESSOR’S PARCEL # ____________________
_____________________________________________________ ______________________
SIGNATURE OF PROPERTY OWNER
DATE
______________________________________________________
ARIZONA DEPT. OF ENVIRONMENTAL QUALITY
__________________
DATE
MOHAVE COUNTY ENVIRONMENTAL QUALITY/
___________________
DATE
WASTE MANAGEMENT REPRESENTATIVE
TempAgreement-BHC
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Completed 3 November 2020

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