| APPLICATION FOR
ON-SITE SEWERAGE FACILITY
CONSTRUCTION PERMIT AND LICENSE TO OPERATE
| I.D. #165012 |
Please Do Not Write In This Block |
|
|
Permit #_____________________________ |
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| [ ] New Installation |
Date Issued__________________________ |
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| [ ] Modification |
Amount_____________________________ |
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| [ ] Original Date _______________
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County Tax No._______________________
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| 1. |
Property Owner's
Name________________________________________________________________ |
|
Last
First
MI |
| 2. |
Permanent Mailing
Address____________________________________________________________ |
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Street No/P.O. Box Number |
|
_________________________________________________________________________________ |
|
City
State
Zip |
| 3. |
Telephone
No._____________________ _________________________
______________________ |
|
Home
Business
At Property |
| 4. |
Site
Address_______________________________________________________________________ |
|
Number
Street
City
Zip |
| 5. |
Directions:
Location of Septic System____________________________________________________ |
|
_________________________________________________________________________________ |
|
_________________________________________________________________________________ |
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Appraisal Office #
699-4991
Tax Office # 688-1195 |
| 6. |
Lot____________
Block________________ Subdivision_________________ Section___________ |
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Recorded
Date___________________ Tract______________________ Unit___________________ |
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| 7. |
If other than
Subdivision:_____________________________________________________________ |
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Acreage
Survey
(Vol/Page Date) |
| 8. |
Builder or Agent's
Name______________________________________________________________ |
|
Phone Number |
| 9. |
Mailing
Address____________________________________________________________________ |
|
Zip |
| 10. |
Source of water:
Private Well_________________ Public Water Supply________________________ |
| |
Name |
THE FOLLOWING INFORMATION
MUST BE COMPLETED BEFORE A PERMIT WILL BE ISSUED.
| Soil
Texture_______________________ Source or Attached
Results__________________________________ |
| House_____________ Mobile
Home_______________ Number of Bedrooms___________________________ |
| Type of Pipe at
Stubout_________________________ |
Depth of Stubout_____________________________ |
| Tank Size in
Gallons____________________________ |
Living Area Square
Feet________________________ |
Single Family Dwelling (one or two bedrooms) - less than 1,500 square
feet.___________________________ |
|
Single Family Dwelling (three bedrooms) - less than 2,500 square
feet._______________________________ |
|
Single Family Dwelling (four bedrooms) - less than 3.500 square
feet.________________________________ |
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Single Family Dwelling (five bedrooms) - less than 4,500 square
feet.________________________________ |
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Single Family Dwelling (six bedrooms) - less than 5,500 square
feet._________________________________ |
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Greater than 5,500 square feet, each additional 1,500 square feet or increment
thereof.___________________ |
| If Business then
type___________________________ |
Number of Employees__________________________ |
| Floor drains
present____________________________ |
Number of shifts
worked________________________ |
| Use of
drains_________________________________ |
Estimated water
consumption____________________ |
| Tank is made
of_______________________________ |
Tank Manufacturer's
Name______________________ |
| Two compartments or two tanks in
a series________________________________________________________ |
| Drainfield pipe type &
diameter___________________ |
Lateral lines are
gravelless______________________ |
| Lateral lines are leaching
chambers________________ |
Number of leaching
panels______________________ |
| Excavation width/bed
size_______________________ |
Excavation
length_____________________________ |
| Media Type_________________________________ |
Geotextile Fabric
Type_________________________ |
| Square feet in
drainfield________________________ |
Linear feet in
drainfield_________________________ |
If your Septic System is any of the
types below it MUST have design approval by a Professional Engineer or Professional
Sanitarian.
| Pressure Dosing |
Composting Toilet |
Mound System |
| Surface Irrigation |
Aerobic Treatment |
Gray Water System |
| Sewage Recycling |
Evapotranspiration Beds |
|
|
|
|
| Site Evaluator's
Name__________________________ |
Certification No.___________ |
Phone_____________ |
| Designer's Name______________________________ |
License No._______________ |
Phone_____________ |
| Installer's
Name______________________________ |
Certification No.___________ |
Phone_____________ |
If you cannot install the septic system
and meet all of the requirements shown below, is there a signed variance form
attached?______________________
MINIMUM SET BACK AND INSTALLATION
REQUIREMENT (IN FEET)
| From: |
To
Tank |
To Drainfield |
Yes |
No |
| Private Water Wells (Yours and
Neighbors) |
50 |
100 |
_____ |
_____ |
| Public Water Wells |
50 |
150 |
_____ |
_____ |
| Water Lines |
5 |
10 |
_____ |
_____ |
| Property Lines |
5 |
10 |
_____ |
_____ |
| Streams and Ponds (including dry
ones) |
50 |
75 |
_____ |
_____ |
| Sharp slopes (with tank
supported) |
0 |
25 |
_____ |
_____ |
| Foundations |
5 |
15 |
_____ |
_____ |
| Easements |
1 |
15 |
_____ |
_____ |
| Soil Absorption System |
5 |
20 |
_____ |
_____ |
| Swimming Pools |
5 |
15 |
_____ |
_____ |
| All excavation at least 3 ft.
apart |
|
|
_____ |
_____ |
| All excavations are 150 ft. or
shorter |
|
|
_____ |
_____ |
| Will step downs be installed? |
|
|
_____ |
_____ |
| All excavations maximum 5 ft.
deep. |
|
|
_____ |
_____ |
Use the attached sheet to sketch how
you intend to install the septic system. You must indicate NORTH on the
diagram and include the following:
|
Water well locations, both yours and the
neighbors' |
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Proposed and existing structures |
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Fences and Easements |
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Proposed and existing water and service lines |
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Property lines |
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Length of all lines, solid and perforated |
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Existing and abandoned septic systems,
cesspools, boreholes |
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Cleanouts: at foundation, at alignment
changes, every 50 feet to tank |
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Distance from streams, ponds, lakes, and
flood plain if applicable. |
DIAGRAM SHEET (Attach sketch
here)
ALL PORTIONS OF THE
SOIL ABSORPTION FIELD MUST BE LEVEL
It is hereby stipulated
and agreed by the undersigned, who is the applicant for such permit, that in consideration
of the issuance of such permit, the said applicant will conform with all the provisions of
Texas Construction Standard for Private Sewage Facilities, and with all orders that may be
made from time to time by the Health Office, and it is further stipulated and agreed that
the Health Office, or his representative, is granted permission to inspect the premises
and system of the undersigned insofar as it pertains to the provisions of Texas
Construction Standards for Private Sewage Facilities.____________________________________
If using gravelless pipe or
leaching chambers, are you familiar with their installation guidelines?____________
It is further agreed that an
inspection by the Midland Health Department must be made before backfill is done,
and a fee of $60.00 will accompany this application for permit. This permit shall be
valid for a period of one year.
Decisions and inspections
relating to the installation of this septic system may be appealed by Administrative
Hearing. Details may be obtained by contacting the Environmental Section of the
Health Department.
If you are purchasing or
refinancing this house, your mortgage company may require a certified water sample.
The Health Department Laboratory can test the water sample for you.
__________________________________________________
Applicant's Signature
NO INSPECTION WILL BE
SCHEDULED FOR 24 HOURS FOLLOWING RECEIPT OF APPLICATION TO ALLOW SUFFICIENT REVIEW TIME
| __________________________________________ |
Please return this application
to: |
|
Date of Approval |
Midland Health and Senior
Services |
|
Environmental Section |
| By________________________________________ |
P.O. Box 4905 |
| Designated
OSSF Inspector |
(3303 West Illinois, Sp. 22) |
|
Midland, Tx 79704 |
|
Phone: 432-681-7613 |
Installer notified to
begin construction
| [ ] Telephone |
[ ] Office |
[ ] Field |
Date________________ |
You must have the following documents to complete
this application:
|
