APPLICATION FOR CONSTRUCTION PERMIT
SEWER EXTENSION
1.1 NAME OF PROJECT
1.2 LOCATION OF PROJECT
2.1 OWNERS NAME PHONE NUMBER
ADDRESS CITY STATE ZIP
PARCEL NUMBER
3.1 BRIEF DESCRIPTION
3.2 DESIGN INFORMATION
A. Population or number of lots to be served by this extension: _________
B. Estimated flow to be contributed by this extension: ________________
C. Industrial Waste: Type: ______________________________________
Flow: _______________________________________
D. Receiving Sewer: Size: ______________________________________
Capacity: ___________________________________
__________________________________________________________________________
3.3 RECEIVING TREATMENT FACILITY NAME OR TYPE OF TREATMENT PLANT
LOCATION OF TREATMENT FACILITY
4.1 HAS THE CONTINUING AUTHORITY WHICH OPERATES THE TREATMENT
FACILITY AND/OR COLLECTION SYSTEM APPROVED OR AGREED TO ACCEPT
THE ADDITIONAL SEWAGE FLOW?
____________________YES _____________________ NO
4.2 I CERTIFY THAT I AM FAMILIAR WITH THE INFORMATION CONTAINED IN THE
APPLICATION, THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF SUCH
INFORMATION IS TRUE, COMPLETE AND ACCURATE, AND IF GRANTED THIS
PERMIT, I AGREE TO ABIDE BY THE RULES AND REGULATIONS SETFORTH BY
THE TANEY COUNTY REGIONAL SEWER DISTRICT.
APPLICANT’S SIGNATURE (SEE INSTRUCTIONS) DATE
PRINT NAME TITLE OR CORPORATE POSITION
INSTRUCTIONS FOR FILLING OUT APPLICATION FOR
CONSTRUCTION PERMIT– SEWER EXTENSION
1.1 Give the name of the project or the name of the subdivision in which the sewers are being
constructed.
1.2 Describe the location by street name or give the most accurate alternative geographic
information
2.1 Legal name and address of the owner or applicant.
2.2 Legal name and address of the continuing authority if different from owner or applicant (if
same, write same). For more information on continuing authorities, see Section (3) of 10 CSR
20-6.010, Construction and Operating Permits.
3.1 Briefly describe the project by providing the following information:
A. Total number of manholes
B. Size of sewers and the total lineal feet of each size
C. Number of lift stations and design average and peak flow capacities of each lift station
D. Size and length of force main
3.2 Self-Explanatory
3.3 Provide the name and address of the treatment facility. In the alternative, the treatment facility
may be described as a three-cell wastewater stabilization pond, 40,000 gpd extended aeration
treatment facility etc. If the treatment facility has no address, provide the most accurate
geographic information.
4.1 If the continuing authority has not agreed to accept the additional flow or in some cases to
accept the sewer extension, this application will be considered incomplete.
4.2 All applications must be signed as follows:
A. For a corporation, by an officer of at least a level of plant manager;
B. For a partnership or sole proprietorship, by a general partner or the proprietor;
C. For a municipal, state, federal or public facility, by either a principal executive officer or
ranking public official;
D. For private project, owner of record.
This completed form, along with the construction permit fee should be returned to the address shown
at the top of the page of the application form.
If there are any questions concerning this form, please direct your questions to:
John Soutee, Administrator
P.O. Box 206
Forsyth, Mo 65653
417-546-7220
e-mail johns@co.taney.mo.us
