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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: