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Request for Wastewater Permit
Work to be performed:
Soil Pit Excavation, Soil Interpretations, Stake wastewater system, Prepare/submit Plans to ADH.
Email documents to:
rg.earthtechinc@gmail.com
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Email
*
Your email
CONTACT DETAILS
Person requesting the work
Name
*
Your answer
phone number
*
Your answer
APPLICANT DETAILS
This information will be used for the permit application
Name of the current landowner
*
Your answer
County property is located in
Your answer
Address of property for permit (if not available provide nearest address, intersection or coordinates)
Your answer
Name of permit applicant
Your answer
Applicant phone number
*
Your answer
Applicant mailing address (permit will be mailed here)
*
Your answer
Applicants email
*
Your answer
FACILITY DETAILS
type
NA
if not applicable
Is the wastewater system for a dwelling or business?
*
Dwelling
Business
Other:
For dwelling, what is the number of bedrooms?
*
type
NA
if not applicable
Your answer
If for a business, what will be the number of employees per day and what type of work will be done in the business?
type
NA
if not applicable
Your answer
What is the square footage of heated and cooled space of the house or business? (see fee schedule below)
*
Your answer
Arkansas Department of Health Permit Fee Schedule
If the property is in a subdivision, provide the lot number and name of the subdivision.
*
type
NA
if not applicable
Your answer
What is the name of the water provider? (If it is a private well, type "well")
*
Your answer
Comments, Special Requests
Your answer
IMPORTANT!
Please confirm the following have been done before we go to the job site:
*
Property corners are flagged and/or easily visible.
Provide a boundary survey. If not available, provide a copy of the property deed.
Property must be accessible to an excavator
Stake the proposed house and driveway location, or provide a sketch with measurements to property lines showing locations.
Required
BILLING INFORMATION
Person responsible for payment to Earthtech.
Provide name, address, phone number and email.
Your answer
A copy of your responses will be emailed to the address you provided.
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