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APPLICATION FOR PERMIT TO INSTALL A SEWAGE DISPOSAL SYSTEM Alpine County Health and Human Services Agency Environmental Health 75-B Diamond Valley Road, Markleeville, CA 96120; [PHONE REDACTED]; [PHONE REDACTED] - fax PLEASE COMPLETE APPLICATION TO THICK BLACK LINE AND RETURN TO THIS OFFICE WITH APPLICABLE PERMIT FEE AS SHOWN ON ATTACHED TABLE. THREE COPIES OF THIS APPLICATION FORM, WITH THREE COPIES OF THE SITE PLAN OF THE SEWAGE DISPOSAL SYSTEM SHALL BE SUBMITTED PROPERTY INFORMATION: Property Owner(s) Mailing Address City, State, Zip Telephone Number Number Assessor’s Parcel Block Lot INSTALLER INFORMATION: Owner or Contractor (if contractor, please provide following information) Installer Cont. License Number Company Number Business Address City, State, Zip WATER SUPPLY: Individual Mutual Public Utility (name) TYPE OF STRUCTURE: Residence Number of Bedrooms Commercial SEPTIC SYSTEM DESIGN INFORMATION: Septic Tank Leaching Field Leaching Pit Leaching Bed Alternative System Size No. of Laterals Size Size Distribution Box Length of Each Depth of Rock Depth of Rock Engineered System below drain tile below drain tile ft. of aggregate below drain tile Trench Width DATE OF WORK: Start Completion I hereby agree to comply with all regulations of the Alpine County Health Department and with all ordinances and laws of the County of Mono and State of California pertaining to septic system construction, repair, modification, and destruction. APPLICANT’S SIGNATURE: DATE SEWAGE DISPOSAL PERMIT NO. (Valid for Twelve (12) Months from Date of Issue) VERIFICATION OF CONTRACTOR’S LICENSE $ FEE PAID ON REC # This certifies that permission is hereby granted to TO INSTALL THE ABOVE SEWAGE DISPOSAL SYSTEM in accordance with the above application. By: Environmental Health Specialist Date CERTIFICATE OF COMPLETION: Environmental Health Specialist Date INSPECTIONS REQUIRED: Open Trench Prior to Backfilling Additional inspections required for Alternative or Engineered Systems (WHEN SIGNED BY THE HEALTH OFFICER, THIS APPLICATION IS A PERMIT) SEWAGE APP (Revised: 01/07/2013)