RILEY COUNTY PLANNING & DEVELOPMENT
110 Courthouse Plaza
MANHATTAN, KS 66502
(785) 537-6332, EXT. 7505
APPLICATION:
REPAIR WASTEWATER SYSTEM
I, _____________________________________________________________, apply to repair or modify a private
wastewater disposal system to serve a ________ bedroom family dwelling which is or will be located on a tract
described as follows:
Repair address: ________________________________________________________________________________
(Street) (City) (Zip Code)
Legal Description (copy may be attached): _________________________________________ Lot size: __________
D
irections to property:____________________________________________________________________________
M
ailing address: _________________________________________________________________________________
(Street) (City/State) (Zip Code)
Home Phone
__________________ Work Phone ___________________ Cell Phone ___________________
Email address: __________________________________________________________________________________
Name of licensed installer: ___________________________________________________________________
C
ause of failure: _________________________________________________________________________________
I h
ereby certify the information on this application is true and correct to the best of my knowledge and belief.
D
ate: ________________________ Signature of applicant: ___________________________________________
P
reliminary proposal approved this ________ day of ___________________, ________ with conditions and/or remarks
as follows:
b
y: __________________________________________
PRIVATE WASTEWATER DISPOSAL SYSTEM USE PERMIT
Final construction is approved and permit is hereby issued this ______ day of ________________, ________,
by: __________________________________________________
Y:\Forms\Enviromental\Fillable PDFs This form expires one year after issue.
Log #__________________
Date rec’d______________
Receipt # ______________
Pd: check ………. #______
cash…………._______
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signature
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