Central Utah Public Health Department

Waste Water System Permit Application

Office Only:

Permit Number: _________

Archive ID: ______________

____

Applicant Information:

Name: ________ Phone: _____________

Mailing Address: _______________ ________ ____

Waste Water System Location: ______________________________________________

County: __________ Town/City: ___________________ GPS: _____________________

System dimensions, lot layout, trench cross section, and other required information must be shown on the diagram page.

Water Source: Public: Name of system: ______________________________________

Private: Well (grouted Y/N) or Spring or Other: ___________

Distance from Waste Water System: _______________________________

Installation Contractor: __________________________ License Number: _________________

This Waste Water System will meet min. requirements of the Central Utah Public Health Department if constructed as proposed. Permit

application and fee must be submitted and a permit issued prior to any construction. Also, system must be inspected prior to backfilling.

Signed: Date: Permit Fee:

(Environmental Health Scientist)

This waste water system is designed for:

A. Single Family Dwelling.

No. of Bedrooms ______________

Unfinished Basement? Y / N

B. Other _______________________

No. People Served _____________

gallons per day estimated waste

water flow ___________________

Size of tank* required:

__________________________gallons *Tank must be from an approved manufacturer.

Total sq ft absorption area required*:

________________________________ *As determined by est. flow and soil type.

Type of absorption system:

A. Standard Trench

B. Chambered Trench

C. Absorption Bed

D. Deep Wall Trench

E. Other: _____________________

Notes: __________________________

________________________________

System Designer Certification: I, _______________________________ certify that I hold a current level two onsite system

professional certification and I have designed the system in accordance to the standards of UT Admin Code R317-4 Onsite

Waste Water Systems.

Certificate Number: ______________________ Signature: ____________________________________ Date: ___________

Central Utah Public Health Department Soil Log/Percolation Test Record Sheet

Name: ________________________________ Date: ___________

Soil

Percolation

Test #

Total Depth of

Hole (ft)

Period of

Time Hole

Presoaked

Period of

Time Soil

Allowed to

Swell

Initial

Depth of

Water

Beginning

Time

Final

Depth of

Water

Ending

Time

Distance

Water

Dropped

Elapsed

Time

Perc.

Rate in

Min/in

Final Stabilized Percolation Rate _________ Minutes per Inch

Particle Size Distribution (percent)

Soil Layer

Depth Intervals

Soil Texture

Soil Structure

USCS

Group

Symbol

Stone

Cobbles

Gravel

Sand

Silt &

Clay

1. Maximum Seasonal Ground Water Elevation: _______________

2. Distance from Wells Within 1500’ of System: ________________

I, _________________________ certify the above information to be an actual description of the Physical Site

Characteristics of the proposed subsurface wastewater disposal system.

Signature: _______________________________________ Certification No.: _______________________ (Certified Soil Tester)

Central Utah Public Health Department

N

Sketch Wastewater System diagram in this space

Standard & Deep Wall Trench Cross Section:

Name: ______________________________________________________________________________________ Date: _____________

Site Location: __________________________________________________________________________________________________

(Show street address or attach legal description of system location)

System Designer: __________________________ (Please Print)

Other Absorption System Cross Section: (i.e. Chambered, Absorption Bed, etc…)

Sketch Cross Section in this Space if Applicable

Earth Backfill (6” min.)

Barrier Material Straw (2”min.) or pervious

material (i.e. synthetic filter fabric)

Perforated Distribution Pipe

(min. 4” diameter)

Drain Media Sewer Rock (3/4 -2.5” diameter)

-2” min. Over Pipe

-6” min. Under Pipe

Coarse Drain Media Drain Media Rock

(3/4-12” diameter)

Standard Trench

(2’ min. separation)

Deep Wall Trench

(4’ min. separation)

Max. Ground Water

Elevation

This Area for

Use in Deep

Wall Trenches

Trench

Width ______

Total

Max. Depth ______

Min.

Depth

of Rock ______

Under

Pipe

4’ min.

Separation

Unsuitable Soil or

Bedrock Formation

Show All Measurements 1. Locate all features which pertain to the wastewater disposal system

in the site area indicated above. Plan must include the following:

a. Buildings

b. Water Service Lines

c. Property Lines Within

15’of Sewer System

d. Wells

e. Septic Tanks

f. Absorption System

g. All Water Courses

h. Soil Test Locations

i. Driveways

j. Existing trees

k. Contour Lines with

Reference marks

Note: This application is only a guide. However, all information required on this form must be submitted. Other plans and information may be

submitted as a substitute or in addition to this application.

Overfill slightly to allow for

settling

Ground Surface

│

│ __ __

Waste Water System Permit Frequently Asked Questions By Brad Johnson, LEHS

Central Utah Public Health Department So, you want to settle out in the country, enjoy the peace, quiet, and open spaces. But you just can’t get away from big city luxuries like indoor plumbing. You’ll need a waste water system for that. Here’s answers to common questions about the waste water system permit process to help you along. How do I get a waste water system permit? You need to fill out an application that includes a system design and soil test. The application is usually filled out by the person who does the soil test and system design. Once the application has been reviewed and approved by the health department a waste water system permit can be issued after fees are paid. How much does a permit cost? Fees are based on the required tank size of the system. For systems with tank sizing of 1000 -2500 gallons the fee is $365.00. For systems with tanks sized 2501 – 5000 gallons the fee is $395.00. Where can I find a list of soil testers?

The state keeps an updated list on the following website: http://www.waterquality.utah.gov/Onsite/OnsiteProfList.pdf

How long is a permit good for? Permits expire after a year from the day it was issued. It can be extended for up to two years but you will need to contact the Health Department before it expires for an extension. Can I install a system myself? A homeowner can install their own system. But we highly recommend using a licensed contractor with experience in installing septic systems. What if I want to change the system design after the permit is issued? The Health Department will need to review and approve any changes to the system design to ensure it still meets code. Where can I go for more information on septic systems? Check out our website at: http://www.centralutahpublichealth.com/wastewater.html