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

 
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:  
*Zip: -  
*Day Phone: () -      
Email:
Is the LANDOWNER same as APPLICANT?
APPLICANT
*First Name:  
*Last Name:  
*Address:  
*City:  
*State:  
*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:   Map #: Parcel #:
(a) In a subdivision? 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:  Note: Each bedroom is considered 150 gpd
(c) How many occupants?: *(d) Excavated Basement?:
(e) Basement Plumbing Fixtures?:
(f) Amount of water used monthly (in gallons): (gallons)
*(g) Water Supply:
*(h) Is the lot staked?: If not, date it will be staked:  
     *Is the house staked?: If not, date it will be staked:  
(i) Installer, if known:
5. FOR INSPECTION LETTER AND CERTIFICATE OF VERIFICATION ONLY
*Delivery Option:
(a) Age of house:  Year(s) *(b) Is house vacant?   *How long?   Month(s)
(c) Original sewage system inspected? Date of original sewage system inspection:  
(d) Date of previous repairs:   Date of previous inspection:  
(e) Is waste water "backing up" into plumbing fixtures?: Surfacing on the ground?
(f) *All waste water including washing machines routed into septic tank?
6. FOR WATER SAMPLE ONLY
*(a) Source of Supply:
*(b) Is there an outside faucet? *(c) Is the source chlorinated?
(d) For Wells: Is the casing 6" above the ground? Is a sanitary seal on the casing?
7. FOR SUBDIVISION EVALUATION/PLAT APPROVAL ONLY
*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:
 
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
WILLIAM R. SNODGRASS TENNESSEE TOWER, 10TH FLOOR
312 ROSA L. PARKS AVENUE
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: