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PSDS Permit App fill-in2016.10.19 File Number:________________ Date Received:______________ Tax Roll No.: __________ PRIVATE SEWAGE DISPOSAL SYSTEM PERMIT APPLICATION FORM Development Permit No.: Estimated Project Completion Date (mmm/dd/yyyy): _________________________________ Permit Applicant:  Owner Contractor Value of Installation (labour and material): $ Work has not started  Work is in progress  Work is complete Owner / Applicant: _____________________________________________________ Mailing Address: City: Province: Postal Code: Phone: Cell: Email: Fax: Contractor: Mailing Address: City: Province: Postal Code: Phone: Contractor Name: Cell: Email: Fax: Project Location: Municipality: County of Newell Subdivision Name: Street/Rural Address: Postal Code: Lot: Block: Plan: Legal Subdivision: Section: Township: Range: West of: Directions: Submit with Application:  Soil Log Report (2 test pits) Soil Analysis System diagram CSA-B66 Certificate Site Plan/Diagram Please Provide a Detailed Description of Work: *** NOTE THAT WORK MUST BE INSPECTED BEFORE COVERING *** TYPE OF WORK INSTALLATION TREATMENT DISPOSAL METHODS Commercial/Conventional New Complete all applicable items: Industrial/Conventional Alteration Septic Tank Size:Serial No.: Residential/Conventional Expected Volume of Effluent:Holding Tank Size:Serial No.: Commercial/Advanced m³/day Treatment Mound Size:(sand layer)  ft² m² Industrial/Advanced Litres/day Disposal Field Size: (trench bottom)  ft² m² Residential/ Advanced Gallons/day Depth of Water Table:Feet Inches Work Camp/No. of Men:(not to exceed 25 m³/day)Open (surface) Discharge Sewage Lagoon Packaged Sewage Treatment Plant Sand Filter No. of Bedrooms (residential including Other: basement and future development): FOIPP Notification: The personal information required by the County of Newell application forms is collected under the authority of section 33(c) of the Alberta Freedom of Information and Protection of Privacy Act and will be protected under Part 2 of that Act and section 63 of the Safety Codes Act. It will be used for processing permit applications, issuing permits, safety codes compliance monitoring and verification. The name of the permit holder and nature of the permit may be included on reports provided to the municipality or made available to the public as required or allowed by legislation. Please direct any questions about this collection to the County of Newell at 403-362-3266 or 183037 Range Road 145, PO Box 130, Brooks, AB T1R 1B2. Certified Installer’s Name (print) Certified Installer’s Signature Homeowner ‘s Signature (homeowner permit only) Homeowner Declaration: By signing this application I hereby certify that I own/will own and occupy this dwelling. Private Sewage Installer’s Certification No.: PS Office Use Only Permit Fee: $ SCC Levy: Issuing Officer’s Name: Total Cost: $ ($4.50 or 4% of the permit fee maximum $560.00) Issuing Officer’s Signature: Receipt No.: Designation No.: Cash  Debit  Cheque Permit Issue Date (mmm/dd/yyyy): 183037 Range Road 145 P.O. Box 130 Brooks, AB T1R 1B2 Phone: 403-362-3266 | Fax: 888-361-7921 | www.countyofnewell.ab.ca