PROPERTY OWNER_________________________________PHONE______________________________
ADDRESS __________________________________________________________________________
LOCATION OF PROPERTY______________________________________________________________
TAX MAP___________   BLOCK____________   PARCEL______________   LOT_______________
CONTRACTOR___________________________ADDRESS______________________________________
CONSTRUCTION TYPE:   New___  Remodeling___  Addition___
PLANNED USE: If Residence_____ No. Bedrooms____ No. People_____ Lot Size_____
             If Commercial____ No. of persons using sanitary facilities______
GARBAGE DISPOSAL______ BASEMENT_______ LIST FIXTURES______________________________
APPLICANT NAME___________________________________  PHONE__________________________
ADDRESS___________________________________________________________________________
APPLICANT SIGNATURE______________________________  DATE___________________________
SEWAGE DISPOSAL SYSTEM MUST BE INSPECTED BEFORE BEING COVERED
* * * * * DO NOT WRITE BELOW THIS LINE * * * * *

PROPOSED SEWAGE DISPOSAL SYSTEM
FACILITY TYPE:  Public Sewer______  Urban Sewer____  Septic tank system____
SEPTIC TANK:  Water Capacity___________ gal.  Distance from:  House______  Well_____
__________________________________________________________________________________
__________________________________________________________________________________
EFFLUENT DISPOSAL:    Distance From:     House______________    Well__________________
If tile field... Length____  Width____   Depth_____         No. trenches_______________  
___________________________________________________________________________________
___________________________________________________________________________________
Installer Name____________________________Address_________________________________

PROPOSED WATER SUPPLY SYSTEM
SOURCE OF SUPPLY: Municipal___ Private___ Driven___ Drilled___Depth___ Diameter___
DISTANCE FROM:  House_____ Septic tank_____ Disposal field_____ Property Line_____
Well Driller/Driver______________________ Address_________________________________

INTERIM PERMI This permit is for an interim individual water system and an interim individual sewage system. The applicant must discontinue individual system and connect to community systems when community systems become available.
PERMIT IS NON-TRANSFERABLE AND EXPIRES IN 24 MONTHS

PROPOSAL APPROVED___________________________________________ DATE______________
INSTALLATION APPROVED_______________________________________ DATE______________
REMARKS________________________________________________________________________