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MARICOPA COUNTY ENVIRONMENTAL SERVICE DEPARTMENT ONSITE WASTEWATER PROGRAM (Maricopa County Telecommunications)

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The MARICOPA COUNTY ENVIRONMENTAL SERVICE DEPARTMENT ONSITE WASTEWATER PROGRAM (Maricopa County Telecommunications) form is 1 page long and contains:

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  • 6 check-boxes
  • 45 other fields

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MARICOPA COUNTY ENVIRONMENTAL SERVICE DEPARTMENT
WATER & WASTE MANAGEMENT DIVISION
ONSITE WASTEWATER PROGRAM
501 North 44th Street, Suite 200, Phoenix, AZ 85008
Phone: (602) 506-6666 Fax: (602) 506-6925
Email: SepticQuestions@maricopa.gov Website: esd.maricopa.gov
APPLICATION FOR SETBACK DISTANCE REVIEW
OF EXISTING SEPTIC SYSTEMS
February 2020 Page 1 of 1 P&D Review Application
OSWP Application #:
Application instructions, general directions, fees, required application submittal items (checklist), and information regarding the license application process as required by
A.R.S. §11-1606, including the permit application process, applicable licensing time frames, county contact information, website and electronic contact information, and
required notices, can be found at
http://www.maricopa.gov/2495/Forms-Applications. The applicant is responsible for the information and requirements listed under the
application instructions. Application submittals that do not meet the requirements of the application instructions, including items listed on the submittal checklist, may
result in a denial of the application. This application will expire one year from the date of submittal.
1. PROJECT INFORMATION:
DATE SUBMITTED:
REVIEW TYPE:
Standard (Review Fee - $80)
Expedited (Review Fee - $
160)
PROJECT DESCRIPTION:
2. SITE LOCATION:
Subject Property Address:
City:
ZIP Code:
Cross Streets:
Parcel Number:
Recorded Deed Number:
Subdivision:
Lot Number:
Township:
Range:
Section:
Parcel Square Footage:
3. PROPERTY OWNER:
2
All documents from MCESD will be mailed to this address unless otherwise noted below. Returned mail will not be forwarded.
NAME:
Telephone:
Mobile:
E-mail:
Facsimile:
ADDRESS
2
:
City:
State:
ZIP Code:
4. CONTACT PERSON/AGENT (IF DIFFERENT THAN THE OWNER):
ORGANIZATION:
CONTACT PERSON:
Title:
Telephone:
Mobile:
E-mail:
Facsimile:
ADDRESS:
City:
State:
ZIP Code:
5. EXISTING/REQUIRED PERMITS: List any county, state, or federal environmental permits issued or needed for the proposed project (check all that apply):
Existing OSWTF permits Description/Permit Number:
Building Authority permit Agency: Permit Number:
6. APPLICANT CERTIFICATION:
READ CAREFULLY AND SIGN BELOW, this section is to be completed by the owner or contact person/agent identified on the first page of the application:
I , certify that this application and all attachments were prepared under the direction or authorization of the owner or
operator of the facility and all information is, to the best of the owner’s or operator’s and my knowledge, true, accurate and complete. I also certify that the on-site
wastewater treatment facility described in this form is or will be, under the direction or authorization of the owner or operator of the facility, maintained and operated in
accordance with terms and conditions the General Aquifer Protection Permit(s) (A.A.C. R18-9-E302 through R18-9-E323) and applicable requirements of A.R.S. Title
49, Chapter 2, the Arizona Administrative Code, Title 18, Chapter 9 regarding Aquifer Protection Permits, and the Maricopa County Environmental Health Code. The
owner or operator of the facility and I am aware that there are significant penalties for submitting false information including permit revocation as well as the
possibility of fine and imprisonment for knowing violations.
Signature: Date:
Owner Agent
FOR INTERNAL USE ONLY
Amount: $______________ Date Issued __________________ Issue Status ________________________ By _________________________
Expedite reviews undergo the first substantive review in half of the time of a
standard review and applies only to first substantive review.
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MARICOPA COUNTY ENVIRONMENTAL SERVICE DEPARTMENT ONSITE WASTEWATER PROGRAM (Maricopa County Telecommunications)

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Completed 6 August 2020

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