Accessible text transcript

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MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
ONSITE WASTEWATER TREATMENT SYSTEM
CONSTRUCTION PERMIT APPLICATION
Application Number
Introduction
Thank you for contacting us concerning plans for your onsite wastewater treatment system (OWTS).
Construction of your OWTS may not begin until a permit has been issued. To expedite this process, please follow
these steps:
1. Contact an OWTS registered contractor. A registered contractor will best be able to assist you with this
process and is highly recommended. State statute requires that “Any person installing on-site sewage
disposal systems shall be registered to do so by the Department of Health and Senior Services.” You also
may choose to submit all of the information and install the system yourself. However, the services of a
registered person to conduct an onsite soil morphology or a percolation test will be required. A registered
contractor should be able to help you select a system to suit your needs and will help you fill in the forms. You
may also consult with the permitting authority representative.
2. There are two option for submitting the “Onsite Wastewater Treatment System Construction Permit Application
Fee” form and payment.
a. Fill in the form and submit it, along with the $90.00 fee, to the address on the form.
b. Pay online by going to https://health.mo.gov/about/online-payment.php. Include the Approval
Number on the form where indicated and either mail form to Missouri Department of Health and
Senior Services, Onsite Wastewater Treatment Program, PO Box 570, Jefferson City, MO,
65102 or fax to (573) 526-7377 .
NOTE: The Construction Permit Application is sent to a different address than the Permit Application Fee.
3. Use the “Onsite Wastewater Treatment System Construction Permit Instruction and Checklist” form to ensure
that all of the required information has been gathered. Then, submit the completed application, soil
morphology report, and all necessary drawings and plans to the office from which you received the packet.
4. Upon receipt of the completed application, the permitting authority representative will schedule a site visit. If
the results of the site visit and plan review are satisfactory and the permit application fee has been received,
the permit will be issued and construction may begin.
If you or your contractor needs additional information, or if we can help you with this in any way, please feel free to
contact us.
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Application Number
MISSOURI DEPARTMENT OF HEALTH
AND SENIOR SERVICES Office Use Only
ONSITE WASTEWATER TREATMENT SYSTEM
Permit Number OWTS Notice of Violation
CONSTRUCTION PERMIT APPLICATION
1. Property Owner Name (Last, First, MI)
Reviewed By EPHS #
EPHS Signature
Developer Y N -- Developers need to contact DNR
2. Site Address (911/ENS) Subdivision Name Lot #
City County Zip Code Date of Subdivision/Lot Plat Total Number of Lots
Parcel ID # Latitude Longitude
¼ ¼ Section Township Range
3. Mailing Address (if different from above) Day Phone Number Night Phone Number
Street City State Zip Code
Directions to Site
4. System Is (Select One) New Construction System Replacement System Repair System Expansion
5. System Serves Residence: Single-Family Multi-Family Business(es) No.: Daily Sewage Flow
(gallons per day)
Laundry Garbage Disposal Food Service
No Bedrooms:
Lodging
Dishwasher Oversized Bath Other (specify):
No Occupants:
Public Name of Public Water Supply:
6. Water Supply Private Type: Bored Well Dug Well Driven Well Drilled Well
Other (specify):
7. Lot Size # acres # square feet % Slope Indicate direction of slope on Site Layout
8. Soil Information Include percolation test or soil morphology report with t he application
Percolation Test Percolation Rate (min/inch)
Soil Morphology Application Rate (gpd/sq. ft.)
9. Name of Percolation Tester or Soil Evaluator Tester Identification Number
Phone Number
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10. Proposed System Complete information only for the system you plan to construct.
A. Waste Stabilization Pond Pond Seal
Dimensions
Native Soil Artificial Liner
Length x width or diameter
Bentonite Clay Clay from Another Source
Total Water Surface Area sq. ft.
Working Depth Type of Equipment Used to Compact Soil:
B. Sewage Tank Absorption Field
Type Distribution Type Product Size
Distribution Box Pipe & Gravel-width
Septic Tank Liquid Capacity gal.
Serial Distribution Chamber-width
Manufacturer: Material/Construction
Flat Lot Layout Gravelless Pipe-dia
Dosed EPS Bundle(s) No
(# of rows per trench)
NSF Class I Aeration Unit Treatment Capacity gpd Pressure Distribution Other (specify)
Manufacturer: Material/Construction
Trench Bottom sq.ft.
Absorption Area:
Pump Tank Liquid Capacity gal. Alternative System Area sq.ft.
Manufacturer: Material/Construction Laterals
Individual Trench Length(s) Total Trench Length
Holding Tank Liquid Capacity ft. ft.
gal.
Trench Width Used Equivalency Trench Width
Manufacturer: Material/Construction in. in.
No. of Trenches Trench Depth
in.
Setback Distance from Septic Tank Class I Unit Pump Tank Absorption Field Lagoon
Owner’s Well
Neighbor’s Well
Public/Community Well
Water Lines
Property Line
Foundation
House
Basement
Stream, River, Pond or Lake
Other (Specify)
C. Alternative System
Low Pressure Pipe System Sand Filter Mound System Drip Irrigation Wetlands
Other (specify) Include supporting data, calculations, and drawings with the packet.
11. Installer Registered: Y N Identification Number: Date of Expiration:
Name Phone Number
Address: (If homeowner, please provide Address, City, State and Zip Code.)
All information contained in and with this application packet is true and accurate to the best of my knowledge.
12. Signature of Owner or Agent Date
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13. Site Layout
1. Show property lines and dimensions to reflect the shape and Slope Diagram
size of the property. Show percent slope on diagram. Show cross section of system on
slope.
2. Diagram proposed system. Show appropriate elevations to
indicate proper fall for system. System must be staked on
the property prior to the site evaluation.
3. Show distances to house, well, water lines, property lines
geological features such as sinkholes, rock outcrops, lakes,
ponds, streams, rivers, etc.
4. Show distances to neighbors’ wells, homes, and sewage
disposal systems.
5. Show locations of all percolation test holes or soil
morphology test pits. Holes must be flagged on the property
for site evaluation.
6. Show discharge pipe, fence, gate and all setback distances
location around waste stabilization pond.
7. Use the slope diagram to show percent slope. Use arrows
on the Site Layout to indicate the direction of slope.
8. Indicate any known easements that exist for utilities, roads,
private driveways, or other easements.
MO 580-2180 (07-20) E3.05