PERMIT TO CONSTRUCT, INSTALL, OR MODIFY
SMALL WASTEWATER FACILITIES
Please complete this application
form in full, including pertinent attachments.
The application must contain the original and one (1) copy of each of the
following: application form, plans, pertinent design
information sheets, plan sheets, and percolation test results.
Submit the completed application form to the Washakie County Planning
Office in the Washakie County Courthouse, 1001 Big Horn Avenue, Suite 107,
Worland, WY 82401.
1. Name of Owner/Permitee: _______________________________________________
Address:
_____________________________________________________________
Telephone Number: _________________
2. Name and Company of Installer ___________________________________________
Address:
_____________________________________________________________
Telephone
Number: _________________
3. Location of facility. Township ____
Range ____ Section ____ ¼
Section _______
4. Type of Application. (Circle correct type)
New Replacement
system
As built
5. Briefly describe facilities proposed to be constructed and/or reason for replacement.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
This form must be signed by the owner, or in the case of the
owner being a corporation or other business organization, by an individual with
the legal authority to bind the corporation or business organization.
I certify that to the best of my knowledge and
understanding the application for a permit for the above described facility in
Washakie County, Wyoming shall be constructed as authorized under the provisions
of any permit issued pursuant to
W.S. §35-11-301(a)(iii) and (v) and other applicable State and County law.
_________________________________________
________________________
Owner (Please print or type)
Title
_________________________________________
________________________
Owner’s Signature
Date
For Office use only: Application Number ____________________
Date Permission Issued _______________________ By:__________________________
Date Inspected _____________________________ By:__________________________