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Cole County Health Department On-Site Sewage Disposal System Construction Permit Application

  1. New Construction?*
  2. Repair of Existing System?*
  3. Residence?*
  4. Residence Type*
  5. Business?*
  6. Business Type
  7. Street Address
  8. Mailing Address Same as Physical Address?*
  9. Water Supply*
  10. Acres
  11. Quantity
  12. Type of Private Well*
  13. Whirlpool?
  14. Dishwasher?*
  15. Laundry Facility*
  16. Garbage Disposal?*
  17. Water Softener*
  18. Type of On-Site Sewage System
  19. Sewage/Pump Tank Information*
    If Applicable is selected additional questions will display.
  20. Gallons
  21. Quantity
  22. Is Tank Aerated?*
  23. Is System Pumped or Dosed?*
  24. Gallons
  25. Set Back Distances from the Sewage Tank
  26. Feet
  27. Feet
  28. Feet
  29. Feet
  30. Feet
  31. Sewage Field and Set Back Distance Information*
    If Applicable is selected additional questions will display.
  32. Square Feet
  33. Type of Distribution*
  34. Geoflow, Pipe, & Gravel etc.
  35. Inches
  36. Inches
  37. Feet
  38. Quantity
  39. Feet
  40. Feet
  41. Feet
  42. Feet
  43. Feet
  44. Feet
  45. Lagoon Information
    If Applicable is selected additional questions will display.
  46. Feet (Length x Width)
  47. Feet
  48. Square Feet
  49. Is Artificial Liner or Imported Clay Required?*
  50. Feet
  51. Feet
  52. Feet
  53. Feet
  54. Feet
  55. Feet
  56. Feet
  57. Site Diagram Design Drawing
    A site diagram design drawing MUST be attached and submitted with this form.
  58. SIGNATURE REQUIRED
  59. DATE REQUIRED
  60. $200 Permit fee is required for any new construction upon submitting the application with the Cole County Health Department.
  61. $50 Permit Fee is required for any repair or modification upon submitting the application to the Cole County Health Department.
  62. All applicable or required information must be completed before application is approved.
    Please contact the Cole County Health Department Environmental Staff with any questions at 573-636-2181.
  63. Office Use Only
  64. Application Approved?
    Office Use Only
  65. Office Use Only
  66. Office Use Only
  67. Office Use Only
  68. Leave This Blank: