Ford County Planning, Zoning		Wastewater Facility Permit Application (septic)
	and Environmental Health		Office Use Only
	100 Gunsmoke, Dodge City, KS 67801		Parcel #:
	Phone:  (620) 227-4670		Permit #:
	Fax:  (620) 227-4717		Location of Proposed Septic system           Section             Township          Range
	http://www.fordcounty.net
Owner Information			Applicant Information (if different)
Name of applicant			Name of applicant
Mailing address			Mailing address
City	State	Zip Code	City	State	Zip Code
Telephone #	Email address		Telephone #	Email address
Intended Use  (circle applicable use)			Draw plan here (include dimensions, ground slope, wastewater systems, water wells, natural bodies of water, corrals, outbuildings, and other potential sources of contamination.  Please include an arrow indicating north):
New system	Modify existing system		systems, water wells, natural bodies of water, corrals, outbuildings
Septic System Information       # Acres ______________			and other potential sources of contamination.  Please include
Site address:			an arrow indicating north:
Distance from well (insert on next line):
Feet from ___ N ____ S       Feet from ____ E  ____  W
Distance to public sewer:  _________ feet ____________
Natural ground slope (direction):  _______________________
#_____ abandoned wells present
#_____ feet from well
Existing septic tank capacity:  _____ gallons
Type of water supply:  (circle)     Public     Private
Does all wastewater enter septic tank?    Yes     no
No. of bedrooms _____   No. of baths _____  Occupants _____
Last date existing septic tank was pumped:  ___________
Septic tank material:
Area of Existing Absorption field:
Contractor name & phone:
Your Responsibilities:
1.  Septic permit is not transferable.  Fees are non-refundable.
2.  The application is good for one year from date of application.
3.  The sanitarian must be contacted for final inspection before covering the system & placing in operation.
4.  You may be prosecuted under state and county laws for failure to comply with the laws governing this application.
5.  The issuance of permit does not guarantee the wastewater system will satisfactorily operate.
6.  This application does not relieve you from responsibility to other federal, state, or local agency's requirements.
7.  You are required to maintain this system in a manner that will keep it from becoming a health or safety hazard.
Owner statement:   I hereby submit this application for a permit to construct and operate a private wastewater system.  I certify the information presented to Ford County on this application to be factual and true.  I further certify, if the application is approved, this system will be constructed in accordance with the system's permit requirements, KDHE's Bulletin 4-2, the requirements of the Ford County Sanitarian and the County Environmental Code.
Owner signature:			Date:
This application and the attached plan are approved for construction.  This application expires after one year.  See septic installation requirements.
Ford County Sanitarian signature:			Date:
Final Inspection	Y / N  Comments			Requirements
Trenches 3 feet deep?	Chamber, GEO-textile or straw?		Size determined:	perc test _____ minutes/inch
Tank 10 feet from house?	End-run risers installed?		Area required:
System 50 feet from well?	Trenches Uniform & level?		Tank capacity
Laterals 10 feet from tank?	Joints glued, screwed, or cemented?		Required pump?
Tank properly baffled, sealed & level?			Septic tank material:            concrete  fiberglass     plastic (POLY)
Inspected by:			Effluent Disposal:  Pipe & Rock laterals, bed, chamber, city sewer,
Comments:			holding tank ___ gal., lagoon ___ gal., mound system, sand filter, soil cond.
Well:	Latitude			Longitude
Driveway:	Latitude			Longitude
Septic:	Latitude			Longitude