Gallatin City-County Health Department Wastewater Treatment System Application Instructions
This form contains 115 fields organized into 38 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Applicant / Agent Information | ||
| Applicant/Agent Name | Text |
Enter the full name of the applicant or agent.
|
| Applicant/Agent Phone Number | Text |
Enter the phone number for the applicant or agent. Fill only if 'Applicant/Agent Name' is filled.
Depends on:
Applicant/Agent Name
|
| Applicant/Agent Mailing Address Line 1 | Text |
Enter the street address or first line of the mailing address for the applicant or agent. Fill only if 'Applicant/Agent Name' is filled.
Depends on:
Applicant/Agent Name
|
| Applicant/Agent City | Text |
Enter the city for the applicant or agent's mailing address. Fill only if 'Applicant/Agent Name' is filled.
Depends on:
Applicant/Agent Name
|
| Applicant/Agent State | Text |
Enter the two-letter state abbreviation for the applicant or agent's mailing address. Fill only if 'Applicant/Agent Name' is filled.
Depends on:
Applicant/Agent Name
|
| Applicant/Agent Email | Text |
Enter the email address for the applicant or agent. Fill only if 'Applicant/Agent Name' is filled.
Depends on:
Applicant/Agent Name
|
| Applicant/Agent Zip Code | Text |
Enter the zip code for the applicant or agent's mailing address. Fill only if 'Applicant/Agent Name' is filled.
Depends on:
Applicant/Agent Name
|
| Application Purpose | ||
| New | Checkbox |
Check this box if the application is for a new wastewater treatment system.
|
| Upgrade/Expansion | Checkbox |
Check this box if the application is for an upgrade or expansion of an existing wastewater treatment system.
|
| Permit Modification | Checkbox |
Check this box if the application is for a modification to an existing permit.
|
| Application Type | ||
| Plumbed Detached Structure | Checkbox |
Check this box if the application involves a plumbed detached structure and requires completing the Detached Structure Section.
|
| Multiple-User | Checkbox |
Check this box if the application is for a multiple-user system serving 3 to 14 connections or units.
|
| Public | Checkbox |
Check this box if the application is for a public system serving 15 or more connections/units, or if it serves 25 or more people per day for 60 or more days per year.
|
| Approval Information | ||
| Certificate of Subdivision Approval Number | Text |
Provide the Certificate of Subdivision Approval (COSA) or Release of Sanitary Restrictions number.
|
| Public System Approval Number | Text |
Provide the Public System Approval (EQ) number.
|
| Authorized Agent Designation | ||
| Authorized Agent Name | Text |
Please enter the full name of the individual or organization designated to act as your authorized agent.
|
| Agent Designation Detail | Text |
Please provide any additional details for the authorized agent's designation, such as a title, department, or organization name.
|
| Commercial Unit Details | ||
| Number of Commercial Units | Text |
Please provide the total number of commercial units. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Business Nature and Failure Description | Text |
Please describe the nature of each business that will be served and any potential failure, if applicable, being specific in your explanation. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Commercial Use Confirmation | ||
| Yes | Checkbox |
Check this box to confirm that the structure is for commercial use. Fill only if 'Commercial' is 'Yes'.
Depends on:
Commercial
|
| Compliance Case Status | ||
| Yes | Radiobutton |
The user should check this box if the application is related to an active compliance case.
|
| No | Radiobutton |
The user should check this box if the application is not related to an active compliance case.
|
| Connection Type | ||
| Individual | Checkbox |
Check this box if the connection type is for an individual unit, meaning there is 1 connection or unit.
|
| Shared | Checkbox |
Check this box if the connection type is shared, meaning there are 2 connections or units.
|
| Customer Flow Calculation | ||
| GPD Per Customer | Number |
Please enter the amount of water in gallons per day (GPD) generated per customer. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Total GPD For Customers | Number |
Please enter the total amount of water in gallons per day (GPD) for customers. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Maximum Customers Per Day | Number |
Please enter the maximum number of customers per day. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Employee Flow Calculation | ||
| Max Employees Per Day | Number |
Enter the maximum number of employees expected per day. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| GPD Per Employee | Number |
Enter the estimated gallons per day (GPD) of wastewater generated per employee. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Total Employee GPD | Number |
Enter the total gallons per day (GPD) of wastewater generated by all employees. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Existing Permit Number(s) | ||
| Existing Permit Number(s) | Checkbox |
Check this box if there are existing permit numbers for the wastewater treatment system on the property.
|
| Existing Permit Number | Text |
Please enter the existing permit number for the system. Fill only if 'Existing Permit Number(s)' is 'Yes'.
Depends on:
Existing Permit Number(s)
|
| First Property Owner Signature | ||
| First Property Owner Name | Text |
Please provide the printed full name of the first property owner.
|
| First Owner Signature Date | Date |
Please provide the date of the first property owner's signature.
|
| Floor Drains | ||
| Yes | Radiobutton |
Check this box if there will be floor drains. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if there will not be any floor drains. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Food Service Establishment Details | ||
| No | Radiobutton |
The user should check this box if the septic system will not serve a food service establishment. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Yes | Radiobutton |
The user should check this box if the septic system will serve a food service establishment. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Number and Size of Grease Traps | Text |
Please provide the number of grease traps and their respective sizes. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| General | ||
| Number of Commercial Units | Text |
Enter the total number of commercial units. Fill only if 'Commercial' is 'Yes'.
Depends on:
Commercial
|
| Commercial No | Checkbox |
Check this box if the structure or project is not commercial. Fill only if 'Commercial' is 'Yes'.
Depends on:
Commercial
|
| Signature | ||
| Signature | ||
| Signature | ||
| Geocode | ||
| Geocode | Text |
Please enter the geocode for the property.
|
| Identification Numbers | ||
| Site Evaluation Number | Text |
Please enter the site evaluation identification number.
|
| Groundwater Monitoring Number | Text |
Please enter the groundwater monitoring identification number.
|
| Kitchen Facilities | ||
| Kitchen Facilities - Yes | Radiobutton |
Check this box if the structure(s) will have kitchen facilities. Fill only if 'Plumbed Detached Structure(s)' is 'Yes'.
Depends on:
Yes
|
| Kitchen Facilities - No | Radiobutton |
Check this box if the structure(s) will not have kitchen facilities. Fill only if 'Plumbed Detached Structure(s)' is 'Yes'.
Depends on:
Yes
|
| Owner Certifications | ||
| Owner Attestation Initial | Text |
Enter your initials to attest that you are the legal owner of the property and that the information provided is complete and accurate to the best of your knowledge.
|
| Wastewater System Certification Initial | Text |
Enter your initials to certify that the wastewater treatment system will not serve more than 24 people daily for more than 60 days per year, unless public system approvals are obtained.
|
| Authorization to Construct Validity Initial | Text |
Enter your initials to confirm your understanding that the Authorization to Construct is valid for 24 months unless otherwise specified.
|
| Change in Use Approval Initial | Text |
Enter your initials to confirm your understanding that a change in use or any modifications may require review and approval by the Health Officer.
|
| Inspection Authorization Validity Initial | Text |
Enter your initials to confirm your understanding that the Authorization-to-Construct is valid for a single scheduled inspection and that uninstalled components require a new application.
|
| System Installation Certification Initial | Text |
Enter your initials to certify that the wastewater treatment system will be installed according to state and local regulations for Wastewater Treatment Systems and any conditions specified on the Authorization to Construct.
|
| Permit Modification Section | ||
| Yes | Radiobutton |
Check this box if a permit modification is requested. Fill only if 'Permit Modification' is 'Yes'
Depends on:
Permit Modification
|
| No | Radiobutton |
Check this box if a permit modification is not requested. Fill only if 'Permit Modification' is 'Yes'
Depends on:
Permit Modification
|
| Issued Authorization to Construct | Checkbox |
Check this box if the modification is for an issued Authorization to Construct that is not expired. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Change to existing permit, no physical change | Checkbox |
Check this box if the modification involves any change to an existing permit to operate with no physical change to the wastewater treatment system components. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Reason for Request | Text |
Provide a detailed explanation for the permit modification request. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Plumbed Detached Structure(s) | ||
| Yes | Radiobutton |
Check this box if there is a plumbed detached structure.
|
| No | Radiobutton |
Check this box if there is no plumbed detached structure.
|
| Property Location Details | ||
| Lot/Tract | Text |
Enter the lot or tract number for the property's legal description.
|
| Block | Text |
Enter the block number for the property's legal description.
|
| COS/Minor Sub | Text |
Enter the Certificate of Survey or Minor Subdivision details for the property.
|
| Section | Text |
Enter the section number of the property's legal description.
|
| Township | Text |
Enter the township number of the property's legal description.
|
| Range | Text |
Enter the range number of the property's legal description.
|
| Property Owner Information | ||
| Property Owner Phone Number | Text |
Please enter the phone number of the property owner.
|
| Text | ||
| Property Owner City | Text |
Please enter the city for the property owner's mailing address.
|
| Property Owner Mailing Address | Text |
Please enter the mailing street address for the property owner.
|
| Property Owner Zip Code | Text |
Please enter the zip code for the property owner's mailing address.
|
| Property Owner State | Text |
Please enter the state abbreviation for the property owner's mailing address.
|
| Property Owner Email | Text |
Please enter the email address of the property owner.
|
| Replacement Details | ||
| Replacement | Checkbox |
Check this box if the application is for replacing an existing wastewater treatment system.
|
| Failed? Yes | Radiobutton |
Check this box if the existing wastewater treatment system that is being replaced has failed. Fill only if 'Replacement' is checked.
Depends on:
Replacement
|
| Failed? No | Radiobutton |
Check this box if the existing wastewater treatment system that is being replaced has not failed. Fill only if 'Replacement' is checked.
Depends on:
Replacement
|
| Catastrophic | Checkbox |
Check this box if the failure of the existing wastewater treatment system is considered catastrophic. Fill only if 'Failed? Yes' is 'Yes'.
Depends on:
Failed? Yes
|
| Non-Catastrophic | Checkbox |
Check this box if the failure of the existing wastewater treatment system is considered non-catastrophic. Fill only if 'Failed? Yes' is 'Yes'.
Depends on:
Failed? Yes
|
| Residential Section | ||
| Yes | Radiobutton |
Check this box if the application pertains to a residential property. Fill only if 'Yes' is 'No'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if the application does not pertain to a residential property. Fill only if 'Yes' is 'No'.
Depends on:
Yes
|
| Number of Living Units | Text |
Enter the total number of living units. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Total Residential Flow GPD | Number |
Enter the total residential water flow in gallons per day (GPD). Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Number of Bedrooms per Living Unit | Text |
Enter the number of bedrooms in each living unit, adding one for any unfinished basement. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Living Unit Description and Failure Details | Text |
Provide a detailed description of the living unit(s) and any relevant failure information, if applicable. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Second Property Owner Signature | ||
| Signature | Text |
Please provide the signature of the second property owner.
|
| Property Owner Name | Text |
Please provide the printed full name of the second property owner.
|
| Signature Date | Date |
Please provide the date when the second property owner signed.
|
| Site Address and Parcel Size | ||
| Parcel Size | Number |
Please enter the size of the parcel.
|
| Site Address | Text |
Please provide the physical address of the site.
|
| Sleeping Accommodations Details | ||
| Yes | Radiobutton |
Check this box if the structure(s) will have bedrooms or sleeping accommodations. Fill only if 'Plumbed Detached Structure(s)' is 'Yes'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if the structure(s) will not have bedrooms or sleeping accommodations. Fill only if 'Plumbed Detached Structure(s)' is 'Yes'.
Depends on:
Yes
|
| Number of Bedrooms/Sleeping Accommodations | Text |
Provide the total number of bedrooms or sleeping accommodations in the structure. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Structure Usage Type | ||
| Private/Personal | Checkbox |
Check this box if the structure will be used for private or personal purposes. Fill only if 'Plumbed Detached Structure(s)' is 'Yes'.
Depends on:
Yes
|
| Commercial | Checkbox |
Check this box if the structure will be used for commercial purposes, which requires completing the Commercial Section. Fill only if 'Plumbed Detached Structure(s)' is 'Yes'.
Depends on:
Yes
|
| Structure Use Description | ||
| Structure Use Description | Text |
Please provide a detailed description of how the structure will be used. Fill only if 'Plumbed Detached Structure(s)' is 'Yes'.
Depends on:
Yes
|
| System Design | ||
| Type of System Proposed | Text |
Enter the type of wastewater treatment system proposed for the design. Fill only if 'Residential' or 'Commercial' or 'Mixed Use' is selected.
Depends on:
Residential, Commercial, Mixed Use
|
| Level II or NSF 245 Component: Yes | Radiobutton |
Check this box if the proposed system is a Level II or NSF 245 Component. Fill only if 'Residential' or 'Commercial' or 'Mixed Use' is selected.
Depends on:
Residential, Commercial, Mixed Use
|
| Level II or NSF 245 Component: No | Radiobutton |
Check this box if the proposed system is not a Level II or NSF 245 Component. Fill only if 'Residential' or 'Commercial' or 'Mixed Use' is selected.
Depends on:
Residential, Commercial, Mixed Use
|
| Manufacturer | Text |
Provide the manufacturer of the Level II or NSF 245 component. Fill only if 'Level II or NSF 245 Component: Yes' is 'Yes'.
Depends on:
Level II or NSF 245 Component: Yes
|
| Model | Text |
Enter the model number of the Level II or NSF 245 component. Fill only if 'Level II or NSF 245 Component: Yes' is 'Yes'.
Depends on:
Level II or NSF 245 Component: Yes
|
| Total Design Flow GPD | Number |
Provide the total design flow in Gallons Per Day (GPD) for the wastewater treatment system, combining residential and commercial flows. Fill only if 'Residential' or 'Commercial' or 'Mixed Use' is selected.
Depends on:
Residential, Commercial, Mixed Use
|
| Tank Size and Type | Text |
Describe the size and type of all tanks proposed for the system. Fill only if 'Residential' or 'Commercial' or 'Mixed Use' is selected.
Depends on:
Residential, Commercial, Mixed Use
|
| System User Count Description | ||
| System User Count Description | Text |
Provide a detailed description of how the number of people (employees & customers) using the system will not exceed 24 people per day for more than 60 days a year, if the system is not public. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Third Property Owner Signature | ||
| Third Property Owner Name (Print) | Text |
Please provide the printed name of the third property owner.
|
| Third Property Owner Signature | Text |
Please provide the signature of the third property owner.
|
| Third Property Owner Signature Date | Date |
Please provide the date of the third property owner's signature.
|
| Total Commercial Flow | ||
| Total Commercial Flow | Number |
Provide the total commercial wastewater flow in Gallons Per Day (GPD). Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Usage Type | ||
| Residential | Checkbox |
Check this box if the application is for a residential usage type and you have completed the Residential Section.
|
| Commercial | Checkbox |
Check this box if the application is for a commercial usage type and you have completed the Commercial Section.
|
| Mixed Use | Checkbox |
Check this box if the application is for a mixed usage type and you have completed both the Residential and Commercial Sections.
|
| Wastewater Generation Calculation | ||
| Strength of Wastewater Description | Text |
Please describe the strength of the wastewater if it is categorized as 'Other'. Fill only if 'Other' is selected.
Depends on:
Other
|
| Wastewater Strength | ||
| Residential | Checkbox |
Check this box if the wastewater strength is residential. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other | Checkbox |
Check this box if the wastewater strength is other than residential and provide details in the 'Describe' field. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|