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TETON
AND PONDERA COUNTY HEALTH DEPARTMENT
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Individual
Sewage Disposal System Installation Permit
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Installation For:____________________________________________Phone:_______________
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Mailing Address:________________________________________________________________
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Property Address:_______________________________________________________________
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Legal Description: Qtr Section_________Sec_________Twp__________Rge_______________
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Type of Structure(s) to be Served:_______________New:___________Existing:_____________
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Total Number:
Living Units:_______________Bedrooms: _______________
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NON-DEGRADATION: Provide information that this system is
nonsignificant under the
non-degradation rules.
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If subdivided Parcel, has sanitary restrictions been
lifted? Yes___________No______________
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Method of water supply to the structure(s): Well_____Cistern______Public______Spring______
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Septic Tank Construction with Filter: Concrete_____Other_________No.
of Gallons____________
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Drainfield: Type of tile_________Length of
tile_________Effective Area_________(in square feet)
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Describe Soil Depth to 8 Feet:______________________________________________________
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(soils
data may be needed)
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Depth To First Ground Water:__________________Percolaton
Rate:__________________Min/in
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Distance Of Installation From: Property lines:
Front_________Back_________Side__________
Foundation(s)______Well_____Surface
Water_____Cistern_____
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This system must be inspected before final covering. Please
call the Health Department at
406-466-2150 or 406-271-4036 to schedule a time. If new or more
restrictive conditions are found
before or during installation, the Sanitarian must be notified
before progressing.
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I CERTIFY THIS SEPTIC SYSTEM HAS BEEN INSTALLED ACCORDING
TO CURRENT SEPTIC SYSTEM REGULATIONS
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Signature of
Applicant:_____________________________________________________________
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Signature of
Installer/Contractor:_____________________________________________________
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Plan Approved
By________________________________________________Date_____________
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Sanitarian
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Installation Inspected
By:__________________________________________Date_____________
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Sanitarian
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THIS PERMIT IS VALID FOR ONE YEAR FROM DATE OF ISSUANCE
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