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COMMUNITY DEVELOPMENT DEPARTMENT Application For Onsite Wastewater System 117 NW Lafayette Avenue, Bend, Oregon 97703 | P.O. Box 6005, Bend, OR 97708-6005 (541) 388-6575 cdd@deschutes .org www.deschutes.org/cd Office Use Only Building Permit #: Onsite Permit #: New Installation Minor Alteration Major Alteration Repair Tank replacement Authorization with field visit; or w/o field visit A. Job Site Information and Location (If property is in City limits a Building Permit Release Form signed by the city planning and engineering staff is required) B. Application For: New System Installation Tank replacement Connecting to an existing system Replacing a dwelling with another dwelling The addition of one or more bedrooms Temporary housing/Medical Hardship Personal Hardship Other _____________________________ Property Address: Single Family Dwelling Multi-Family Dwelling Manufactured Dwelling Accessory Structure Commercial/Industrial Water Supply: Well Community Water Supply Other________ C. For New Systems (New Construction Only) Proposed Use of Structure: Full-time Residence Vacation Home Shop Barn Accessory Dwelling Business/Commercial Include a detailed description of the proposal Other, provide description: _______________________________________________________________________ Proposed # of bedrooms: Proposed # of employees: Proposed # of bathrooms: Proposed # of wet bars: Proposed System Type: Standard Capping Fill ATT Sand Filter Pressure Distribution Proposed Tank Material: Steel Concrete Poly Fiberglass Use of sewage ejector pump? Yes No Site Evaluation Permit #: Site Evaluation Date: D. Existing System Information (Required for Authorizations, Alterations, Repairs, & Tank Replacements) Use of Existing Structures: Full-time Residence Vacation Home Shop Barn Accessory Dwelling Business/Commercial, provide description: ______________________________________________________________________________________ Other, provide description: _______________________________________________________________________________________________________ Existing # of bedrooms: Existing # of employees: Existing # of bathrooms: Existing # of wet bars: Existing System Type: Standard Capping Fill ATT Sand Filter Pressure Distribution Existing Tank Material: Steel Concrete Poly Fiberglass Use of sewage ejector pump? Yes No Note: If adequate onsite wastewater records do not exist, you may be required to expose the entire top of a septic tank, junction boxes, the beginning and end of each drain line, and/or dig test pits.

COMMUNITY DEVELOPMENT DEPARTMENT Application For …...☐ New Installation ☐ Minor Alteration ☐ Major Alteration ☐ Repair ☐ Tank replacement Authorization ☐ with field visit;

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  • COMMUNITY DEVELOPMENT DEPARTMENT

    Application For Onsite Wastewater System

    117 NW Lafayette Avenue, Bend, Oregon 97703 | P.O. Box 6005, Bend, OR 97708-6005

    (541) 388-6575 [email protected] .org www.deschutes.org/cd

    Office Use Only Building Permit #: Onsite Permit #:

    ☐ New Installation ☐ Minor Alteration ☐ Major Alteration ☐ Repair ☐ Tank replacement Authorization ☐ with field visit; or ☐ w/o field visit

    A. Job Site Information and Location

    (If property is in City limits a Building Permit Release Form signed by the city

    planning and engineering staff is required)

    B. Application For:

    ☐ New System Installation

    ☐ Tank replacement

    ☐ Connecting to an existing system

    ☐ Replacing a dwelling with another dwelling

    ☐ The addition of one or more bedrooms

    ☐ Temporary housing/Medical Hardship

    ☐ Personal Hardship

    ☐ Other _____________________________

    Property Address:

    ☐ Single Family Dwelling ☐ Multi-Family Dwelling

    ☐ Manufactured Dwelling ☐ Accessory Structure

    ☐ Commercial/Industrial

    Water Supply: ☐ Well ☐ Community Water Supply ☐ Other________

    C. For New Systems (New Construction Only)

    Proposed Use of Structure: ☐ Full-time Residence ☐ Vacation Home ☐ Shop ☐ Barn ☐ Accessory Dwelling

    ☐ Business/Commercial

    Include a detailed

    description of the proposal

    proposed use on separate

    paper.

    ☐ Other, provide description: _______________________________________________________________________

    Proposed # of bedrooms: Proposed # of employees:

    Proposed # of bathrooms: Proposed # of wet bars:

    Proposed System Type: ☐ Standard ☐ Capping Fill ☐ ATT ☐ Sand Filter ☐ Pressure Distribution

    Proposed Tank Material: ☐ Steel ☐ Concrete ☐ Poly ☐ Fiberglass Use of sewage ejector pump? Yes ☐ No ☐

    Site Evaluation Permit #: Site Evaluation Date:

    D. Existing System Information (Required for Authorizations, Alterations, Repairs, & Tank Replacements)

    Use of Existing Structures: ☐ Full-time Residence ☐ Vacation Home ☐ Shop ☐ Barn ☐ Accessory Dwelling

    ☐ Business/Commercial, provide description: ______________________________________________________________________________________

    ☐ Other, provide description: _______________________________________________________________________________________________________

    Existing # of bedrooms: Existing # of employees:

    Existing # of bathrooms: Existing # of wet bars:

    Existing System Type: ☐ Standard ☐ Capping Fill ☐ ATT ☐ Sand Filter ☐ Pressure Distribution

    Existing Tank Material: ☐ Steel ☐ Concrete ☐ Poly ☐ Fiberglass Use of sewage ejector pump? Yes ☐ No ☐

    Note: If adequate onsite wastewater records do not exist, you may be required to expose the entire top of a septic tank, junction boxes,

    the beginning and end of each drain line, and/or dig test pits.

  • Application For Onsite Wastewater System

    (Continued)

    June 2019

    E. Proposed Changes (Required for Authorizations, Alterations, Repairs, & Tank Replacements)

    ☐ Fix failing or sub-standard system ☐ Add a bathroom to a new or existing accessory structure

    ☐ Add a bedroom to single family dwelling ☐ Add a bedroom to a new or existing accessory structure

    ☐ Change a residential use to a commercial use (Include information about the proposed

    operation and specific information regarding wastewater characteristics and the size of the flow)

    ☐ Other (provide details below)

    Detailed Description :________________________________________________________________________________________________________________

    _____________________________________________________________________________________________________________________________________

    ______________________________________________________________________________________________________________________________________

    Total # of proposed bedrooms (existing + new): Total # of proposed employees (existing + new):

    Total # of proposed bathrooms (existing + new): Total # of proposed wet bars (existing + new):

    F. Proposed Modifications to Septic System (Required for Authorizations, Alterations, Repairs, & Tank Replacements)

    ☐ Use existing system as is ☐ Replace septic tank (only) ☐ Add drainfield Add sewage ejector pump?

    Yes ☐ No ☐☐ Other ___________________________________________________________________________________

    G. Property Owner Information

    Owner Name: Email:

    Mailing Address: Phone #:

    H. Installer Information

    Business Name: Installer Name:

    Business Address: DEQ License #:

    Phone #: Email:

    I. Applicant Information

    Applicant Name:

    Applicant Address:

    Phone #: Email:

    All information provided in this application is complete and accurate and does not contain omissions. Incomplete applications

    may delay the application review and permitting process.

    Signature: Date:

    Sharepoint: Permit Application Packet

    117 NW Lafayette Avenue, Bend, Oregon 97703 | P.O. Box 6005, Bend, OR 97708-6005

    (541) 388-6575 [email protected] .org www.deschutes.org/cd

  • COMMUNITY DEVELOPMENT DEPARTMENT

    Onsite Wastewater System Application

    Requirements

    117 NW Lafayette Avenue, Bend, Oregon 97703 | P.O. Box 6005, Bend, OR 97708-6005

    (541) 388-6575 [email protected] .org www.deschutes.org/cd

    ☐ Completed Onsite Wastewater Application Form and applicable fees

    ☐ Completed Authorizing Representative Form (if applicable)

    ☐ Two copies of scaled, legible, and detailed site plans with the following information:

    Arrow indicating North

    Property description, including township, range, section, and tax lot number and

    subdivision name, lot, and block number where applicable

    Location, size, and intended use of all existing and proposed structures, driveways, access

    roads, decks, patios, pastures, outbuildings, etc.

    Location of wells within 100 feet of the drainfield (including neighboring properties)

    Location of any public utility or other easements (canals, overhead power lines/poles)

    Drainageways, creeks, streams &/or seasonal wet depressions

    Location of all major features (i.e.: canals, irrigation ditches, rock ledges, etc.)

    Dimensions of all property lines

    Names and location of all streets or roads adjacent to the property

    Topographic contours or direction and percent of slope

    Existing and proposed tank and drainfield

    Relative elevation of the native soil surface at the septic tank top, at both ends of all

    trenches and in the center of each trench

    Distance from tank to first distribution or drop box

    Replacement drainfield

    ☐ Pump curve with selected pump model and hydraulic calculations used to determine Total

    Dynamic Head and Net Discharge

    ☐ Signed Operations and Maintenance contract

    ☐ DEQ Approved Specification sheet/s (For ATT only)

    ☐ Sand Filter schematic (For Sand Filter only)

    For All Onsite Wastewater Permits

    For Sand Filter, Pressure Distribution, & Alternative Treatment

    Technology (ATT) Systems

  • COMMUNITY DEVELOPMENT DEPARTMENT

    Example Site Plan

    April 2018

    Onsite Wastewater System Application_updated 4.16.18Onsite Wastewater Systems Application Requirements_updated 4.16.18Example Site Plan

    Building Permit: Onsite Permit: Property Address: Single Family Dwelling: OffManufactured Dwelling: OffCommercialIndustrial: OffMultiFamily Dwelling: OffAccessory Structure: OffWell: OffCommunity Water Supply: Offundefined_8: OffOther: New System Installation: OffTank replacement_2: OffConnecting to an existing system: OffReplacing a dwelling with another dwelling: OffThe addition of one or more bedrooms: OffTemporary housingMedical Hardship: OffPersonal Hardship: Offundefined_9: OffOther_2: Fulltime Residence: OffVacation Home: OffShop: OffBarn: OffAccessory Dwelling: OffBusinessCommercial: Offundefined_10: OffProposed of bedrooms: Proposed of employees: Proposed of bathrooms: Proposed of wet bars: undefined_11: Offundefined_12: Offundefined_13: Offundefined_14: Offundefined_15: Offundefined_16: Offundefined_17: Offundefined_18: Offundefined_19: Offundefined_20: Offundefined_21: OffSite Evaluation Permit: Site Evaluation Date: Fulltime Residence_2: OffVacation Home_2: OffShop_2: OffBarn_2: OffAccessory Dwelling_2: Offundefined_22: OnBusinessCommercial provide description: undefined_23: OffOther provide description_2: Existing of bedrooms: Existing of employees: Existing of bathrooms: Existing of wet bars: undefined_24: Offundefined_25: Offundefined_26: Offundefined_27: Offundefined_28: Offundefined_29: Offundefined_30: Offundefined_31: Offundefined_32: Offundefined_33: Offundefined_34: OffFix failing or substandard system: OffAdd a bedroom to single family dwelling: OffChange a residential use to a commercial use Include information about the proposed: OffAdd a bathroom to a new or existing accessory structure: OffAdd a bedroom to a new or existing accessory structure: OffOther provide details below: OffTotal of proposed bedrooms existing new: Total of proposed employees existing new: Total of proposed bathrooms existing new: Total of proposed wet bars existing new: Use existing system as is: OffReplace septic tank only: OffAdd drainfield: OffN: Offundefined_37: OffOther_3: Offundefined_38: Owner Name: Email: Mailing Address: Phone: Business Name: Installer Name: Business Address: DEQ License: Phone_2: Email_2: Applicant Name: Applicant Address: Phone_3: Email_3: undefined_39: undefined_40: 06/20/2019undefined_41: Check Box1: OffCheck Box4: OffCheck Box5: OffCheck Box7: OffCheck Box8: OffCheck Box9: OffCheck Box10: OffOffice Use - Minor Alt: OffOffice Use - New Installation: OffOffice Use - Major Alt: OffOffice Use - Repair: OffOffice Use - Tank Replacement: OffOffice Use - Auth With Visit: OffOffice Use - Auth w/o Visit: OffOther provide description: New System - Bus/Com - Provide Description: Detailed Description: