RILEY COUNTY PLANNING & DEVELOPMENT
110 Courthouse Plaza
MANHATTAN, KS 66502
(785) 537-6332, EXT. 7505
APPLICATION:
WASTEWATER SYSTEM with STANDARD FIELD
I, ________________________________________________________________________, present mailing address is:
______________
__________________________________________________________________ do hereby apply to
(Street) (City/State) (Zip Code)
construct a private wastewater system to serve a ________ bedroom family dwelling which is or will be located at
Property Address:_______________________________________________________________________________
(Street) (City) (Zip Code)
Name
of licensed installer: _____________________________________________ Size of the Property: __________
I hereby
certify the information on this application is true and correct to the best of my knowledge and belief.
Date: ________________________ Signature of applicant: ____________________________________________
Home
Phone ________________ Work Phone ________________ Cell Phone __________________
Emai
l address: ___________________________________________________________________________________
Pre
liminary proposal approved this ________ day of _________________________________, ______ with conditions
and/or remarks as follows:
by: __________________________________________
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______________
Pd: check ………. #______
cash…………._______
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
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_______________________________________________________________________________________
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