Fillable TTT PDF Planning IHS Water And Utility Application 092014 (The Tulalip Tribes)

Fill Online, Printable, Fillable, Blank TTT PDF Planning IHS Water And Utility Application 092014 (The Tulalip Tribes) Form

Use Fill to complete blank online THE TULALIP TRIBES (WA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

TTT PDF Planning IHS Water And Utility Application 092014 (The Tulalip Tribes)

On average this form takes 31 minutes to complete

The TTT PDF Planning IHS Water And Utility Application 092014 (The Tulalip Tribes) form is 9 pages long and contains:

  • 4 signatures
  • 50 check-boxes
  • 83 other fields

Country of origin: US
File type: PDF

U.S.A. forms for The Tulalip Tribes

BROWSE THE TULALIP TRIBES (WA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
INDIAN HEALTH SERVICE
APPLICATION
FOR
INDIVIDUAL
WATER &
WASTEWATER
FACILTIES
Please retain top information section for your records and
return the application section to your tribal IHS liaison.
Homeowner’s Checklist
Here’s what you can expect from the Indian Health Service (IHS) as we install your water or
wastewater facilities and a few things we will need from you to keep your project moving
forward.
Follow the outline, below, of the tasks involved and timelines for completing each phase. All
timelines are approximations and begin after you provide your portion. If, at anytime, through
this process you have questions, please feel free to call the IHS at (206) 615-2794.
Check when completed
Phase 1: Getting Started
What you give us:
A complete IHS application
A copy of your deed or lease to your land
A clear idea of your property’s boundaries
What we do for you – within about 3 weeks after all
documents are received:
Call you to outline the process
Visit your home site to look it over with you and
discuss the plan
Phase 2: Drawing It Up
What you give us:
Any specific information you have regarding the
composition of your land: soils, surveys, well
logs, etc.
Prompt feedback if/when we need it
What we do for you – within about 1 month after all
information is received:
Gather technical information about your property
Plan out your water and wastewater facilities
based on your feedback
Design the facilities and estimate the cost
Apply for septic installation permits
Phase 3: Getting It Done
What you give us:
Access to your nearly completed new or existing
home
What we do for you – within about 1 month after
foundation is complete and power is available:
Solicit bids for and award the contract
Organize the construction schedule
Oversee and inspect construction
Phase 4: Finishing It Off
What you do:
Call the contractor (who is under warranty) to
service your system
Call IHS if the contractor doesn’t respond
Provide feedback--How can we improve?
What we do for you – within about 1 month after
construction is complete:
Provide a “Homeowner’s Information Packet” with
everything to help you understand about caring
for your water or wastewater system
Act as an ongoing resource for questions about
your water or wastewater system
Department of Health & Human Services
INDIAN HEALTH SERVICE
Office of Environmental Health and Engineering (OEHE)
Seattle District Office; 2201 6
th
Avenue, Rm. 925; Seattle, WA 98121; (206) 615-2794
Department of Health & Human Services
INDIAN HEALTH SERVICE
Office of Environmental Health and Engineering (OEHE)
Seattle District Office; 2201 6
th
Avenue, Rm. 925; Seattle, WA 98121; (206) 615-2794
About Us
The Sanitation and Facilities Construction (SFC) Program and the Office of Environmental Health
and Engineering (OEHE) were created within Indian Health Service (IHS) to support necessary
components of IHS. The SFC Program provides American Indian homes and communities with
essential water supply, sewage disposal, and solid waste disposal facilities. SFC and OEHE
environmental engineers plan, design and manage water and wastewater construction projects
for tribal members in Washington State and throughout the nation.
Our goal is to raise the health status of American Indians to the highest possible level by
providing public health services. The SFC Program also supplies technical and financial
assistance to the Tribes for cooperative development and continued operation of safe water,
wastewater, and solid waste systems and related support facilities.
What is an Onsite Sewage System?
An onsite sewage system (OSS) is also known as a septic system. OSS are designed to help
prevent the spread of illness and disease by collecting, treating and dispersing wastewater from a
home or business into the native soils near that building.
An OSS is typically comprised of two or more components linked together by pipes. There are
two general types of systems used most often in Washington State. The unique site conditions
for each individual lot (e.g., soil type and depth, size of lot, distance to surface waters and wells,
etc.) determine which type of OSS can be installed. Different combinations of components may
be used to best suit site conditions and owner preferences.
General Types of OSS
Standard Gravity OSS
This is the most common type of system and it usually has two main parts: the septic tank and
the drainfield. Sometimes a pump tank is also used in a standard system to transport the effluent
to a drainfield above the septic tank.
Indian Health Service (IHS) strongly recommends pumping the septic tank at least once every
three years.
Alternative OSS
This type of system is required where soil depth and/or other site conditions do not allow a
standard gravity system to be used. IHS highly recommends that alternative OSS have annual
operation and maintenance (O&M) and be inspected at least once a year by a certified
maintenance provider.
Onsite Sewage System: DO’s
DO Know Where Your OSS is Located and Protect it:
Have a copy of your as-built drawing or map the location of all parts of your septic system. IHS or your local health
district can provide you with a copy.
If you move, remember to provide all records and information to new owners or tenants.
Keep a “rainy day fund” to cover possible repair and maintenance costs.
Educate your family, guests or renters on how to care for the system.
DO Inspect Your OSS Yearly:
Keep accurate, detailed records of any repairs and pumping.
Maintain an operations and maintenance contract with a licensed specialist.
DO Use Water Wisely:
Conserve water through the use of low-flow fixtures, doing laundry throughout the week rather than on one specific
day, limit shower length and fix any plumbing leaks promptly.
Direct runoff from roofs, streets, driveways and adjoining property away from the sewage system area.
Keep any irrigation (sprinkler) system at least 10 feet from the edge of the on-site sewage system.
Drain water from hot tubs and water softeners away from the drainfield, storm drains and surface waters.
Onsite Sewage System: DON’Ts
DON’T Compact Soils of Drainfield or Reserve Area in any Way by:
Driving/parking vehicles, boats or heavy equipment in the OSS area.
DON’T Disturb the Drainfield or Reserve Area by:
Building, burning or grazing livestock in the area.
Covering it with landscaping materials—other than grass.
Driving across the sewage system, grading, leveling, filling or cutting the area.
Installing a sprinkler system or planting deep-rooted water-loving plants over the drainfield.
Planting a vegetable garden for human consumption on your drainfield or mound.
DON’T Overload the System by:
Using too much water.
Using a garbage disposal.
Using tank additives or “miracle” septic system cleaners.
Discarding medications or strong household cleaning products down the drain or toilet.
Allowing backwash from water softeners or conditioners.
Pouring shortening or meat fats down the drain (which will turn into solids in cold water).
MOST IMPORTANT: Pump your septic tank at least once every three years!
APPLICATION
For
Individual Site Sanitation Facilities
Portland Area Indian Health Service
Seattle District Office
HOMEOWNER INFORMATION
1. Name(s):____________________________________________________________________________
2. Telephone--Home:_________________ Work:_________________ Cell:_________________
3. Email Address:________________________________
4. Current Mailing Address:_______________________________________________________________
____________________________________________________________________________________
5. Have you previously received sanitation facilities from IHS? __________ If so, what year? _________
6. Of which Tribe are you a member?________________________________________________________
HOMESITE INFORMATION
7. Site Address:__________________________________________________________________________
_____________________________________________________________________________________
8. County:_______________________________
9. Township:__________ Range:__________ Section:__________
10. Directions to/location of home to be served: (from Seattle) ______________________________________
____________________________________________________________________________________
____________________________________________________________________________________
11. Best time of day for IHS site visit: 8 am-Noon__________ Noon-4 pm__________
Note: To make site accessible for visit, please move vehicles and leash animals.
12. Land Status: Trust (Tribal):_____ Trust (Indiv):_____ Fee:_____ Divided Interest:_____
If leased, number of years:__________
Note: A legal deed or lease, establishing the applicant as the owner or lessee, must
be submitted.
13. Type of Home: Stick-built __________ Modular __________ Mobile__________
Note: Mobile homes must be off of wheels and have complete skirting.
14. Year that home was built: __________ Years you have lived in home: __________
15. Number of bedrooms: __________ bathrooms: __________ residents: __________
16. Home is or will be primary residence: Yes: __________ No:__________
17. Home constructed/on site? Yes:__________ No:__________
18. Date home will be constructed/delivered:_________________________________________________
19. Electrical power available at site: Yes: __________ No: __________ If not, when:__________
Note: Construction cannot begin until power is available at site.
20. Existing Water facilities currently at site:
____ Individual Well, with Pump and Pressure System
____ Community Water Connection
____ Are existing facilities failing or insufficient?
____ None
21. Existing Sewer Facilities currently at site:
____ Septic Tank & Drainfield
____ Community Sewer Connection
____ Are existing facilities failing or insufficient?
____ None
22. Likely Water Facilities Requested:
____ Individual Well
____ Well Pump w/Pressure System
____ Community Water Connection
23. Likely Sewer Facilities Requested:
____ Individual Septic Tank/Drainfield
____ Community Sewer Connection
____ Other ____________________
24. Reason(s) for Requested Service:
____ Service to new home
____ Service to rehabilitated home
____ Replacement of failed facilities
____ Other ____________________
25. Please attach the following documents to this application (if available):
- Legal deed or long-term (15+ yr) lease (required)
- Proof of tribal membership
- Legal survey of land by licensed surveyor
- Site plan showing property lines and location of all future or existing buildings, roads, water, etc.
- As-built drawings for existing water or sewer facilities
- Plans showing dimensions of future home
- Proof of any easement required for service
Note: In some cases, property corners set by a licensed surveyor will need to be visible to install sanitation
facilities.
INDIVIDUAL SITE GUIDELINES
HOMEOWNER AUTHORIZATION
I hereby certify that the information in this Application is true and accurate to the best of my knowledge.
I hereby agree:
z To allow IHS or its authorized representatives to enter upon my property to evaluate the site and to
construct or inspect the facilities requested in this application.
z To obtain all easements and permits necessary for the requested sanitation facilities.
z To accept ownership upon completion of the requested sanitation facilities, and to operate and
maintain them in a satisfactory manner.
I understand that these facilities will be provided only if funding is available and if this application meets IHS
qualification requirements.
If requesting an individual septic system, I have read the septic care information attached to this application.
26. ______________________________________________________________ ______________________
Signature of Head of Household Date
TRIBAL AUTHORIZATION
27. The _____________________________ Tribe appoints __________________________________ as liaison
to coordinate Tribal participation in serving this applicant.
Liaison Phone Number:_________________ Fax Number:_________________
Liaison Mailing Address:___________________________________________________________________
___________________________________________________________________
28. Zoning:
Is the proposed home site in conformance with zoning regulations?__________
Is there any reason that this site is not
acceptable for residential construction?__________
Remarks:_______________________________________________________________________________
_______________________________________________________________________________________
29. Land Status Certification: The Tribe has reviewed the applicant’s land status as reported above and hereby
certifies that the information is____ or is not _____ current and accurate.
If not, what is the actual status? __________________________________
30. Tribal Eligibility and Endorsement: This application has been reviewed by the Tribe. The applicant is a member
of a Federal Recognized Tribe and the application is eligible. Therefore; the applicant is recommended for
services.
______________________________________________________________ _______________
Signature of Tribal Chairperson or Liaison Date
Note: Incomplete or unsigned forms will be returned for completion.
INDIAN HEALTH SERVICE ACKNOWLEDGEMENT
31. Application Received:
______________________________________________________________ _______________
IHS Service Request Manager Date
click to sign
signature
click to edit
click to sign
signature
click to edit
1
Name:____________________________________________________Date:______________________
Address:___________________________________City:_____________ST:_________Zip:__________
( address of site area)
Contact Number:_(________)________________ Other Contact Number:__(________)_____________
Site/Project (If Applicable)___________________________________________________________________________________________________
Tulalip Utility Authority
Water – Sewer Service Application and Agreement
PROPERTY OWNERS REQUESTING A CONNECTION TO TULALIP UTILITY’S WATER SUPPLIY SYSTEM MUST
AGREE TO:
Furnish a legal description of the premise to be served.
Specify the location and size of service required.
Pay all charges for the new service connection; in addition pay for Any outstanding combined utility charges.
Provide all approved plans and permits when required.
The property owner acknowledges their financial responsibility for any costs associated with any street or sidewalk resto-
ration required when installing new service.
To allow The Tulalip Utilities or its authorized representatives to enter upon my property to evaluate, construct, or in-
spect facilities listed in application.
Tulalip Utility Authority May:
Disconnect the domestic water supply for nonpayment of any water charges.
Temporarily shut-off any service at any time without notice for emergency repairs.
Reference Title 13
CURRENT PROPERTY OWNER:
Name:________________________________________
Address:______________________________________
APT:____________ST:_________ZIP:_____________
Daytime Phone:_(_________)____________________
Parcel No:______________________________________
Sec:___________Town:_____________Range:_________
Block#:___________________ LOT#:________________
*Please Attached additional documentation
LEGAL DESCRIPTION BILLING ADDRESS
2
Inspector’s Report
Planned Installation Date:____________________________________________________________________________
(Please allow up to 10 working business days for processing)
Date Completed:_________________________________ Signature:__________________________________________
COMMENTS: _____________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Deed/Mortgage:
□ Trust □ Fee Simple □ Other □ Leased
Land Status Certification:
We have had time to review the applicants land status reported above and find that the it:
□ Is correct and accurate □ Is NOT correct and accurate
TRIBAL PERMIT #__________________________________________________________
Date:________________________ Signature:____________________________________
X_________________________________________________________ Phone:_______________________________
Print Name
X__________________________________________________________ Date:_______________________________
Signature of Owner
LAND STATUS
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

TTT PDF Planning IHS Water And Utility Application 092014 (The Tulalip Tribes)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 20 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document