Septic Permit Application

New System or Repair?*

Address/Parcel Number*

Property Owner/Property Owner Agent Name *

Phone Number*

Please enter a valid phone number.

Email Address or Fax*

example@example.com

Installer*

Email Address or Fax

example@example.com

Phone Number*

Soil Evaluator*

Email Address or Fax

example@example.com

Phone Number*

Size of Lot or Tract*

Number of Bedrooms or Building Description*

Water supply?*

PublicPrivate

Proposed System Type (select one)*

Conventional serial distributionConventional pump to gravityConventional pressurized manifoldConventional with dipper or distribution boxLagoon/wastewater stabilization pond (include dimensions in attached design)Alternative system - choose type below (attach design prepared by professional engineer or architect)

If Alternative System (select one)

Drip dispersalLow pressure pipeMoundOther

If Other, Type Answer Below

Tank Type*

Septic tankAerobic treatment unit (ATU)

If Septic Tank, List Tank Size

If ATU, List Treatment Volume (in GPD)

Will System Have a Pump Tank*

YesNo

If Yes, Pump Tank Volume

Attach System Design*

Attach Soil Morphology*

Absorption Field Material

Rock and pipeChambersPeanut pipe/expanded polystyrene productOther

If Other, Please Specify

Trench Width

Trench Depth

Trench Length

Number of Trenches

All permits for on-site wastewater treatment systems will be sent to the applicant and installer electronically.

Actions of representatives of the Platte County Health Department engaged in the evaluation and determination of measures required to effect compliance with the provisions of laws, rules, regulations, ordinances, and policies regarding onsite wastewater treatment systems (OWTS) shall in no way be taken as a guarantee or warranty that an OWTS approved and permitted will function in a satisfactory manner for any given period of time. Due to the development of clogging mats, which adversely impact the life expectancy of normally functioning soil absorption OWTS and variables influencing system function which are beyond the scope of said laws, rules, regulations, ordinances, and policies, no guarantee or warranty is implied or given that an OWTS will function in a satisfactory manner for any

It is the responsibility of the Property Owner/Property Owner's Agent to disclose the locations of property lines, easements, right-of-ways, and other restrictions prior to placement of the system. By signing this application you agree that the all information contained in and with this application is true and accurate to the best of your knowledge and the property owner has given approval for the installation of onsite wastewater treatment system.

For the purposes of this application, the property owner/property owner's agent shall be deemed the applicant.*

Clear

Permit Fee*

Permit Fee

$100.00 Quantity

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Septic Permit Application

Additional Required Information for Conventional Systems Only

Absorption Field Size

Please read the following carefully before signing the application

All permits for on-site wastewater treatment systems will be sent to the applicant and installer electronically.