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Septic Permit Application

2. County of Dubuque<br> Department of Health<br> Environmental Health Division<br> 13047 City View Drive<br> Dubuque, IA 52003<br> Phone: 563-557-7396

   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.

    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

Leave This Blank:


68. 1. Receive an email copy of this form.
69. Email address

    This field is not part of the form submission.

70. Submit

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