A well designed system protects our natural water resources...
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Tax Assessment Roll#:
Date of Application:

SYSTEM TYPE

New Construction Repair Alteration Amendment or Update

Owner's Name(s):
Owner's Mailing Address:
Name of Authorized Person:
Authorized Person Phone Number:
Legal Description of where lot is to be constructed:
Street Address and General Description of lot location:

Sewage System will serve:

Single Family Dwelling Duplex Other
Other Description:

Estimated Daily Sewage Flow:
Number of Bedrooms:
Is there a finished basement:
Do you intend to add a basement suite or more bedrooms in future?:
Total Living area:
Lot Size (acres, sq ft, or sq m):

Type of Sewage Disposal System:

Conventional Privy Lagoon Holding Tank Raised Mounds Seepage Bed Deep Trench Other
Other Description:

Material of Tank:
Liquid Volume of Tank:
Total length of Drainage pipe:
Type of Drainage Pipe:
Inside Diameter of pipe:
Package Treatment Plant (if used) Make and Model:
Treatment Capacity (if used):
Will a sewage pump be used:
Field Dose Volume pumped per cycle:
Is pressure distribution proposed:
Lagoon Size:
Depth of Clay Soil:
Is a garburator to be used:

Site Information:

Is depth of soil over or under 4 feet:
If under is it due to rock or clay, and how deep from surface:
Is depth to water table over four feet:
Who performed the percolation tests:
What is the average slowest rate from each test hole:
Describe the source of your domestic water:
Distance of disposal field to domestic water:
Describe any covenants or easements which restrict the system design:
Do you have a plot plan (with dimensions) that show all (basic) system components: