Fillable SWF applications to the Teton County Engineering Department (Teton County Wyoming Government)

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SWF applications to the Teton County Engineering Department (Teton County Wyoming Government)

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SWF Permit Application
1
Effective 01/12/2021
SMALL WASTEWATER FACILITY PERMIT (SWF) APPLICATION
Planning & Building Services Department
Building Division
Please check all that apply and fill in the blanks:
200 S. Willow St.
Phone : (307) 733-3959
# of bedrooms
P.O. Box 1727
www.tetoncountywy.gov
gal/day
Jackson, WY 83001
Repair
Check box if this is for a failing system.
Physical Address:
Lot, Subdivision:
PIDN:
Name:
(must agree with Deed)
Phone:
Mailing Address:
City, State:
Email:
ZIP:
Name:
Phone:
Mailing Address:
City, State:
Email:
ZIP:
Name:
WY License #:
Email:
Phone:
For Office Use Only
GEC BDR
SWF
SITE LOCATION: (please provide map if difficult to find)
Please submit stand-alone SWF
applications to the Teton County Engineering Department at 320 S. King St. If this application is part of a Building
Permit submission, please bring it to your take-in appointment.
All applications and site plans must be emailed to permits@tetoncountywy.gov before delivering to the Building or Engineering Department.
Please use fillable PDF in lieu of handwritten application.
OWNER: A copy of the Warranty Deed or Contract of Sale must accompany this application.
APPLICANT/AGENT: If the applicant is other than owner, a notarized Teton County Planning & Development Letter of Authorization must accompany this
application. Only the owner or his/her authorized agent may sign the application, correction list or
per
mit.
DESCRIPTION OF PURPOSE OR CONCISE NARRATIVE (EXPLAIN IF FAILED SYSTEM):
DESIGN ENGINEER: All small wastewater facilities must be designed by a licensed Wyoming Professional Engineer.
SWF Permit Application
2
Effective 01/12/2021
Number of Bedrooms:
Number of Bathrooms:
System Design Flow:
gal/day
Gravity or Pressure dose:
Is design sized for future capacity?
Lift station to sewer collection system?
Percolation rate (minutes per inch in each hole):
Hole 1 :
Hole 2:
Hole 3:
Hole 4 :
Hole 5:
Hole 6:
Tests conducted by:
Results of Profile Hole (8’ depth):
Groundwater:
Depth of highest seasonal groundwater:
Date of test:
Test conducted by:
Method used:
Soil Type Classification:
Coarse sandy soil with gravels and cobble (list the percent of gravel)
Fine to sandy loam
Sandy loam to loam
Loam to sandy clay loam
Clay loam
Silty clay loam
Clay
Soil types classifications conducted by:
A fee due at the time of submittal – Public Works Fee Schedule.
Letter of Authorization if the applicant is other than the property owner.
A copy of the Warranty Deed.
One set of legible complete SWF design drawings scaled on 11” x 17” paper.
One PDF set of scaled design drawings and SWF application with all other attachments emailed to permits@tetoncountywy.gov (no larger than 25MB)
STRUCTURE INFORMATION:
WATER SUPPLY INFORMATION: Indicate the proposed drinking water source (private well, public water system, spring, etc.)
GROUNDWATER AND SOILS INFORMATION: Must provide with application (see Teton County SWF Regulations for requirements).
SUBMITTAL REQUIREMENTS:
SWF Permit Application
3
Effective 01/12/2021
I certify that I have read and examined this application and know the same to be true and correct. All provisions of the laws and
ordinances governing this work will be complied with whether specified herein or not. The granting of this permit does not
give authority to violate or cancel the provisions of any state or local law regulating grading or the performance thereof.
Signature of Applicant
Date
Print Name
Title
Questions about SWF Permit Applications should be directed to the Engineering Department (307-733-3317).
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SWF applications to the Teton County Engineering Department (Teton County Wyoming Government)

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Completed 22 January 2021

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