Septic Permit Application

Septic Permit Application
New System or Repair?*

New SystemRepair
Owner/Owner Agent Name*

First NameLast Name
Address/Parcel Number*
Property Owner/Agent Phone Number*
Please enter a valid phone number.
Property Owner/Agent Email Address or Fax*
example@example.com
Installer*
Installer Email Address or Fax
example@example.com
Installer Phone Number*
Soil Evaluator*
Soil Evaluator Email Address or Fax
example@example.com
Soil Evaluator 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
All system designs must have the following:
- Show property lines and dimensions
- Diagram the proposed system, including elevations for proper drainage. Flag or stake the system on the property for evaluation
- Indicate distances to the house, well, water lines, property lines, and natural features like rock outcrops, lakes, ponds, streams, and rivers
- Note distances to neighboring wells, homes, and sewage systems
- Mark locations of soil test pits or percolation holes, which must be flagged or staked for evaluation
- Show the fence around the wastewater stabilization pond, if applicable
- Indicate locations of curtain drains and diversion berms
- Mark existing easements for utilities, roads, and private driveways
Attach System Design*

Cancelof
Attach Soil Morphology*

Cancelof
Additional Required Information for Conventional Systems Only
Absorption Field Material

Rock and pipeChambersPeanut pipe/expanded polystyrene productOther
If Other, Please Specify
Absorption Field Size
Trench Width
Trench Depth
Trench Length
Number of Trenches
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.

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.

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

Should be Empty:

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.