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
4
2
n
r
l A
if
r Pr
i
n P
rmi
____________________________________