Application for Commercial Wastewater System Permit - Cheyenne Laramie County Public Health

Application must include specifications and pertinent design information. All permits issued shall be emailed to all parties.

Fee:(Required)

Inspection Fee: $375

Partial Inspection Fee: $65 (per trip)

Name of facility:(Required)

Address of facility:(Required)

Street Address Address Line 2 City State ZIP Code

Owner, company, or corporation name:(Required)

LOCATION OF FACILITY

Range:(Required)

Township:(Required)

Section:(Required)

Lot:(Required)

Blk.:(Required)

Subd.:(Required)

New facility:(Required)

Modified facility:(Required)

Previous permit number(s):

Briefly describe facilitie(s) proposed to be constructed:(Required)

APPLICANT / OWNER OF RECORD

Name:(Required)

First Last

Name of Business:(Required)

Address:(Required)

Street Address Address Line 2 City State ZIP Code

Phone:(Required)

Email:(Required)

Enter Email Confirm Email

ENGINEER:

Name(Required)

First Last

WY. P.E.#:(Required)

Engr. Firm:(Required)

Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email:(Required)

Enter Email Confirm Email

Phone:(Required)

I certify that the above described facility has been submitted in accordance with local, county, and state statutes, as required, and that said facility shall be constructed as authorized under the provisions specified in Wyoming Water Quality Rules and Regulations, Chapter III and Laramie County Small Wastewater Regulations.

Signature of Owner:(Required)

Draw your signature

Date:(Required)