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TE MARICOPA COUNTY ENVIRONMENTAL SERVICE DEPARTMENT WATER & (Maricopa County Telecommunications)

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MARICOPA COUNTY ENVIRONMENTAL SERVICE DEPARTMENT
WATER & WASTE MANAGEMENT DIVISION
ONSITE WASTEWATER SYSTEMS PROGRAM
501 North 44th Street, Suite 200, Phoenix, AZ 85008
Phone: (602) 506-6666 Fax: (602) 506-6925
Email: SepticQuestions@maricopa.gov Website: esd.maricopa.gov
GENERAL ONSITE APPLICATION FOR PHASE I SI
TE
EVALUATION,
RECONNECT REVIEW OR ABANDONMENT/CLOSURE
February 2020 Page 1 of 2
OSWTF Permit #:
Application instructions, general directions, fees, required application submittal items (checklist), and information regarding the license application
process as required by A.R.S. §11-1606, including the permit application process, applicable licensing time frames, county contact information,
website and electronic contact information, and required notices, can be found at http://esd.maricopa.gov/2495/Forms-Applications. The
applicant is responsible for the information and requirements listed under the application instructions. Application submittals that do not meet the
requirements of the application instructions, including items listed on the submittal checklist, may result in a denial of the application. This application
will expire one year from the date of submittal or one year from Department completed site and soils evaluation.
1. PROJECT INFORMATION:
DATE SUBMITTED:
REVIEW TYPE:
Expedited
1
Site and/or Test Hole Inspection Reconnect / Remodel Plan Review Abandonment/Closure
PROJECT NAME:
PROJECT DESCRIPTION (for Review/Reconnect or Abandonment/Closure, indicate reason for request):
SEWER AVAILABILITY: SEWER
Is Not
available within 400’ of the property
1
Expedited reviews require double the standard permit fee. Expedite reviews undergo the first substantive review in half of the time of a standard review and applies only to first substantive review.
2. SITE LOCATION:
Subject Property Address:
City:
State:
ZIP Code:
Cross Streets:
Parcel Number:
Subdivision:
Lot Number:
Legal Description: Township Range Section
Parcel Square Footage:
Recorded Deed Number:
Recorded Affidavit of Agreement to Encroach Number:
Latitude:
Longitude:
Site Code:
3. PROPERTY/BUSINESS/PROJECT OWNER:
2
Any changes to this address shall be submitted in writing to MCESD within 15 days of the change. All documents from MCESD will be mailed to
this address unless otherwise noted below. Returned mail will not be forwarded.
ORGANIZATION:
NAME:
Title:
Telephone:
Mobile:
Alt. Telephone:
E-mail:
Facsimile:
ADDRESS
2
:
City:
State:
ZIP Code:
Country:
4. CONTACT PERSON/AGENT (IF DIFFERENT THAN THE OWNER):
ORGANIZATION:
CONTACT PERSON:
Title:
Telephone:
Mobile:
Alt. Telephone:
E-mail:
Facsimile:
ADDRESS:
City:
State:
ZIP Code:
Country:
5. PERMIT INFORMATION:
WASTEWATER SOURCE:
Single-Family Residence with typical household sewage
Commercial
Type of Establishment: ____________________________________________________________
Maximum Number of Users (customers, employees, members, etc.): ________________________
February 2020 Page 2 of 2
OSWTF Permit #:
WATER SOURCE: (check one below)
Water Company Water Company Name:
Holding Tank (hauling water)
Private Well Well Identification Number:
Shared Well Shared Well Agreement Recording Number:
6. EXISTING/REQUIRED PERMITS:
List any county, state, or federal 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 or related to the discharge (check all that apply below):
Existing OSWTF permits Description/Permit Number:
Other environmental permits required Description/Permit Number:
Building Authority permit Agency: Permit Number:
Flood Control Authority permit Agency: Permit Number:
7. APPLICANT CERTIFICATION:
READ CAREFULLY AND SIGN BELOW, this section is to be completed by the owner or contact person/agent identified on the first page of
the application:
Pursuant to A.R.S. § 41-1009, the Department may enter your premises to conduct inspections. You have the right to receive a copy of the
Department’s inspection report at the time of the inspection, within thirty (30) days after the inspection, or as otherwise provided by federal law. By
initialing below, I agree that the Department may send me a copy of its inspection report by e-mail to the following email address:
or by facsimile transmission to the following fax number:
, (initials). It is the responsibility of the permit holder to update the Department
if there is a change in contact information.
I , agree it is my responsibility to comply with all applicable statutes, rules, codes, ordinances and regulations
for the work requested. Safety is the responsibility of the property owner or their agent. Request for inspection may be made in person, by phone
(602-506-1787),
e-mail, on-line or fax (602-506-6925). To avoid additional inspection fees, be sure to include access information (e.g. gate
code) and/or other special instructions or requests (e.g. meet inspector at site).
Signature: Date:
Owner Agent
FOR INTERNAL USE ONLY
Amount:
$______________ Date Issued __________________ Issue Status ________________________ By _________________________
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TE MARICOPA COUNTY ENVIRONMENTAL SERVICE DEPARTMENT WATER & (Maricopa County Telecommunications)

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Completed 6 August 2020

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