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Septic Permit Application
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County of Dubuque
Department of Health
Environmental Health Division
13047 City View Drive
Dubuque, IA 52003
Phone: 563-557-7396
Permit Number
Project Number
Applicant Name
Property Owner Name
Applicant Phone Number
Property Owner Phone Number
Address
City
State
Zip Code
Legal Description
Section
Township
Lot Number
Block
Subdivision
Class of Work
Extension
Modify
New
Repair
Replacement
Occupancy
Commercial
Industrial
Multi-Residential
Recreational
Residential
Building / Structure
Commercial / Office Building
Mobile Home
Residential Dwelling
Type of Water Supply
Common Well
Municipal Water
Private Well
Shared Well
Lot Size
Facility Used
Seasonally
Year-round
Number of units to be connected:
Estimated sewage flow:
Number of Bedrooms
Number of Occupants
Building Dimensions
Septic Tank Capacity
Material Type
Dosing Chamber Size
Gravity Dosing
Yes
No
Pressure Dosing
Yes
No
Drop Boxes
Yes
No
Description of Construction:
Special Approvals
Water Softener - Zoning
Not Required
Recommended
Required
Garbage Disposal - Engineer
Not Required
Recommended
Required
Jacuzzi / Whirlpool Tub - IDNR
Not Required
Recommended
Required
N.O.I. - IDOT
Not Required
Recommended
Required
Perc Test
Not Required
Recommended
Required
Soil Boring
Not Required
Recommended
Required
I hereby certify that the above information is correct and that all proposed work will be completed in accordance with the Dubuque County Rules and Regulations regarding Private Sewage Disposal. I also agree to construct the system in accordance to the condition listed herein.
Signature
Date
Date
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