DWR Online Application

TENNESSEE DEPARTMENT OF ENVIRONMENT AND CONSERVATION APPLICATION FOR DIVISION OF WATER RESOURCES SERVICES

Please note, this online application form is not to be submitted for service requests in the following metro/contract counties: Blount, Davidson, Hamilton, Jefferson, Knox, Madison, Sevier, Shelby, or Williamson county. If you need to apply for any of the below services in any of these counties, please click on the county name to visit its website for more information. Please call 615-532-0761 for any questions regarding this form. Items with * prefix are required items 1. SERVICE REQUESTED: (select a service from the below drop-down box) FEES DUE Septic System Construction Permit - Dwelling Septic System Construction Permit - Commercial Septic System Construction Permit - System Modification Septic System Construction Permit - Repair Alternative System Permit Inspection Letter Certificate of Verification Water Sample - Total Coliform Water Sample - Fecal Coliform Subdivision Evaluation Soil Mapping - General Soil Mapping - High Intensity Soil Mapping - Extra High Intensity Plat Approval - Individual Lot Large Conventional System Plan Review Large Alternative System Plan Review Experimental System Plan Review Domestic Septage Disposal Site Permit   Please see note below: Select a service to see the associated fee. Applicant may review these service requests with Enviromental Specialist prior to processing application.

2. LANDOWNER *First Name:   *Last Name:   *Address:   *City:   *State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY   *Zip: -   *Day Phone: () -       Email: Is the LANDOWNER same as APPLICANT? APPLICANT *First Name:   *Last Name:   *Address:   *City:   *State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY   *Zip: -   *Day Phone: () -       *Email:   Confirmation e-mails will be sent to this address and is required for processing of credit card payment. ORIGINAL PROPERTY OWNER Name:

3. LOCATION OF LOT OR SITE *County: Anderson Bedford Benton Bledsoe Bradley Campbell Cannon Carroll Carter Cheatham Chester Claiborne Clay Cocke Coffee Crockett Cumberland Decatur Dekalb Dickson Dyer Fayette Fentress Franklin Gibson Giles Grainger Greene Grundy Hamblen Hancock Hardeman Hardin Hawkins Haywood Henderson Henry Hickman Houston Humphreys Jackson Johnson Lake Lauderdale Lawrence Lewis Lincoln Loudon McMinn McNairy Macon Marion Marshall Maury Meigs Monroe Montgomery Moore Morgan Obion Overton Perry Pickett Polk Putnam Rhea Roane Robertson Rutherford Scott Sequatchie Smith Stewart Sullivan Sumner Tipton Trousdale Unicoi Union Van Buren Warren Washington Wayne Weakley White Wilson   Map #: Parcel #: (a) In a subdivision? Yes No Name: Lot #: Site Address: Site City: Site Zip:  - Please give specific directions and address to the lot or site. In addition, you may add links to mapping sites that show the location, or links to photos, of the site. This space is for any information that may be of use to our personnel in processing your application:

4. FOR SSDS AND ALTERNATIVE SYSTEM PERMITS ONLY (a) Size of lot (in acres): *(b) Number of Bedrooms: 0 1 2 3 4 5 6 7 8 9 10  Note: Each bedroom is considered 150 gpd (c) How many occupants?: *(d) Excavated Basement?: Yes No (e) Basement Plumbing Fixtures?: Yes No (f) Amount of water used monthly (in gallons): (gallons) *(g) Water Supply: PublicWellSpring *(h) Is the lot staked?: Yes No If not, date it will be staked:        *Is the house staked?: Yes No Existing Structure If not, date it will be staked:   (i) Installer, if known:

5. FOR INSPECTION LETTER AND CERTIFICATE OF VERIFICATION ONLY *Delivery Option: Applicant will pick up Mail to Applicant's address (a) Age of house:  Year(s) *(b) Is house vacant? Yes No   *How long?   Month(s) (c) Original sewage system inspected? Yes No Don't Know Date of original sewage system inspection:   (d) Date of previous repairs:   Date of previous inspection:   (e) Is waste water "backing up" into plumbing fixtures?: Yes No Surfacing on the ground? Yes No (f) *All waste water including washing machines routed into septic tank? Yes No

6. FOR WATER SAMPLE ONLY *(a) Source of Supply: SpringWell *(b) Is there an outside faucet? Yes No *(c) Is the source chlorinated? Yes No (d) For Wells: Is the casing 6" above the ground? Yes No Is a sanitary seal on the casing? Yes No

7. FOR SUBDIVISION EVALUATION, SOIL MAPPING, OR PLAT APPROVAL ONLY *For Subdivision Evaluation - Number of Lots: *For Soil Mapping - Number of Acres: *For Plat Approval - Number of Lots:

8. DESCRIPTION OF PROPERTY This can include the directions to property, property lines, house site, well location, spring location, planned driveway and utilities 9. ALL FEES ARE DUE IN ADVANCE AND ARE NON-REFUNDABLE (except on appeal) *Method of Payment: Credit/Debit CardCheck   Note: If the Method of Payment is selected as Check you are required to print the form after submission and mail it with a check to: DEPARTMENT OF ENVIRONMENT AND CONSERVATION DIVISION OF FISCAL SERVICES - CONSOLIDATED FEE SECTION 14TH FLOOR, L & C TOWER 401 CHURCH STREET NASHVILLE, TN   37243

10. CERTIFICATION I certify that the above information is true and correct to the best of my knowledge, and that I have been authorized by the above named landowner to submit Application for Environmental Services to the Division of Water Resources. *DATE:    *SUBMITTER NAME: