Form Center

2. County of Dubuque
   Department of Health
   Environmental Health Division
   13047 City View Drive
   Dubuque, IA 52003
   Phone: 563-557-7396
4. Permit Number
5. Project Number
7. Applicant Name
8. Property Owner Name
10. Applicant Phone Number
11. Property Owner Phone Number
13. Address
15. City
16. State
17. Zip Code
19. Legal Description
20. Section
21. Township
23. Lot Number
24. Block
25. Subdivision
27. Class of Work

    1. Extension
    2. Modify
    3. New
    4. Repair
    5. Replacement
28. Occupancy

    1. Commercial
    2. Industrial
    3. Multi-Residential
    4. Recreational
    5. Residential
30. Building / Structure

    1. Commercial / Office Building
    2. Mobile Home
    3. Residential Dwelling
31. Type of Water Supply

    1. Common Well
    2. Municipal Water
    3. Private Well
    4. Shared Well
33. Lot Size
34. Facility Used

    1. Seasonally
    2. Year-round
36. Number of units to be connected:
37. Estimated sewage flow:
39. Number of Bedrooms
40. Number of Occupants
41. Building Dimensions
43. Septic Tank Capacity
44. Material Type
45. Dosing Chamber Size
47. Gravity Dosing

    1. Yes
    2. No
48. Pressure Dosing

    1. Yes
    2. No
49. Drop Boxes

    1. Yes
    2. No
51. Description of Construction:
53. Special Approvals
55. Water Softener - Zoning

    1. Not Required
    2. Recommended
    3. Required
56. Garbage Disposal - Engineer

    1. Not Required
    2. Recommended
    3. Required
57. Jacuzzi / Whirlpool Tub - IDNR

    1. Not Required
    2. Recommended
    3. Required
59. N.O.I. - IDOT

    1. Not Required
    2. Recommended
    3. Required
60. Perc Test

    1. Not Required
    2. Recommended
    3. Required
61. Soil Boring

    1. Not Required
    2. Recommended
    3. Required
63. 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.
65. Signature
66. Date
    Date
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68. 1. Receive an email copy of this form.
69. Email address

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70. Submit

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