Sewage Disposal and/or Water Supply Permit Type of Sewage System: New Repair Expanded Conditional FHA/VA Yes No Case NumberOwner First Last PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Agent First Last PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Directions of PropertySubdivisionSectionBlockLotOther Property IdentificationsDimension/size of Lot/PropertyOther Application InformationBuilding/Facility New Existing Intermittent Use Yes No If yes, describe Residential Use Yes No Termite Treatment Yes No Single Family (# of Bedrooms) Multi-family (# of Units) Basement Yes No Fixtures in Basement Yes No Commercial Use Yes No Describe: DescribeCommercial/Wastewater Yes No Number of Patrons Number of Employees If yes, give volumes and describeWater Supply Public New Existing Private New Existing DescribeProposed Sewage Disposal Method:Onsite Sewage Disposal System: Septic Tank Drainfield LPD Mound Other Attach a site plan (rough sketch) showing dimensions of property, proposed and/or existing structures and driveways, underground utilities, adjacent soil absorption system, bodies of water, drainage ways, and wells and springs within 200 feet radius of the center of the proposed well or drainfield. Distances may be paced or estimated. The property lines and building location are clearly marked and the property is sufficiently visible to see the topography.Max. file size: 100 MB. The property lines and building location are clearly marked and the property is sufficiently visible to see the topography. I give permission to the department to enter onto the property described for the purpose of processing this application.(Required) Name Date(Required) MM slash DD slash YYYY Last Updated: April 24, 2025
