SITE VISIT REQUEST FORM

SITE VISIT REQUEST FORM
Directions: Fill out the following request form completely and submit the appropriate fee. Minimum requirements for obtaining a subsurface wastewater treatment system may include obtaining a copy of a survey for your property/parcel from the Clerk & Recorder's Office, excavating an 8-foot hole in the area of the proposed drainfield, taking a nitrate sample from an existing or nearby well or providing other information to fulfill the minimum requirements of DEQ 4 and Fergus County Regulations.
PROPERTY OWNER INFORMATION
Applicant Name
Phone Number
Format: (000) 000-0000.
Alternate Phone Number
Format: (000) 000-0000.
Applicant Address
Street Name
City
State
Zip Code
Property Owner Name
Address

Address where system is to be installed

Street Address Line 2

CityState / Province

Postal / Zip Code
PROPERTY INFORMATION
Lot #
Block #
Subdivision Name
COS #
1/4
Section#
Township
Range
# of Acres
Residence/Commercial
# Bedrooms
# People
Geo Code #
County
Other Legal Description
SEPTIC/WATER INFORMATION
NewReplacement
Reason for replacing
Water Supply
If well, depth
Feet
Is the property in the 100 year flood plain?
REQUESTED SITE VIST INFORMATION
Requested Date

MonthDayYear
Requested Time
Directions to property location
This information is correct to the best of my knowledge. I understand that if any of this information is found to be incorrect and/or any restrictions of delinquent taxes placed on this property have not been properly removed at the time the permit is issued this permit/ application will be deemed invalid.
Signature of Site Visit Applicant/Purchaser

Clear
Date

MonthDayYear
Fergus County Fees:

Site Visit Fee- $275
Amount Paid
Check # or Cash
Date Fee Received

MonthDayYear
Date
Payment received by
Site Visit completed by
Purchase Septic Permit?
Should be Empty:

SITE VISIT REQUEST FORM

PROPERTY OWNER INFORMATION

PROPERTY INFORMATION

SEPTIC/WATER INFORMATION

REQUESTED SITE VIST INFORMATION