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

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

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




Onsite Wastewater System Application

Requirements



☐ 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


Example Site Plan

April 2018

Documents

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