Small Wastewater System Permit Application Inspection Fee:(Required) $375 $65 (partial, per trip) Incomplete applications will not be accepted. Landowner:(Required) Phone: (Cell/Home)(Required)Phone: (Work)(Required)Mailing Address:(Required) Street Address 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 Property Address:(Required) Street Address 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 Mandatory before permit will be written.Property TypeRange:(Required) Township:(Required) Section:(Required) Subdivision:(Required) Lot/Tract:(Required) Block:(Required) Proposed Number of Bedrooms:(Required) Basement:(Required) Yes No Please specify if the basement is:(Required) Finished Unfinished Acreage:(Required) Dimensions:(Required) Previously Permitted(Required) Yes No Is this to be a homeowner install?(Required) Yes No Who will be the licensed system installer?: Perc Hole Depth:(Required) How long were holes pre-soaked?(Required) Building Drain Depth:(Required) Date Test Run:(Required) Month Day Year Check One:(Required) Rock Chamber System Readings:(Required)Reading 1Reading 2Reading 3Reading 4Reading 5Reading 6*Reading 7Reading 8** Add RemoveClick (+) for more holes. Perc tests faster than 1 inch in 5 minutes requires engineering approval. A 10 foot site hole is required for new constructionTime Interval(Required) *10 MINUTES/6 READINGS **30 MINUTES/8 READINGS Inspector Notes:Name of person performing tests:(Required) First Last Signature of person performing tests: Reset signature Signature locked. Reset to sign again Draw your signature.Upload sketch and description:(Required) Drop files here or Select files Max. file size: 50 MB. SKETCH home, perc hole location, well, septic tank, drainfield, garage, driveway, easements and drainage ways. Where possible, indicate soil type in drainfield area (perc site). Indicate NORTH. Include location of replacement field. INDICATE ALL WELL LOCATIONS ON ADJACENT PROPERTY(ies). (All wells shall be at least 50' from septic tank and at least 100' from drainfield. Well to drainfield distance may be greater in some subdivisions). DIRECTIONS & DISTANCES TO PROPERTY. BE SURE PERC HOLES ARE OPEN AND MARKED.I, THE UNDERSIGNED LANDOWNER, CERTIFY THAT THE ATTACHED SKETCH IS AN ACCURATE REPRESENTATION OF MY PROPOSED HOMESITE.Landowner Signature(Required) Reset signature Signature locked. Reset to sign again Draw your signature.Landowner Name(Required) First Last Date(Required) Month Day Year Δ