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2. Septic Private Sewage Disposal System Permit
   The permit must be printed and signed and delivered with the $300 permit fee.
4. Date*
   Date
5. Date Payed
   Date Payed
   Office Use
7. who is filling out the form*

   1. Homeowner
   2. Contractor
8. Title Holder's Name*
9. Title Holder's Address *
11. City*
12. State*
13. Zip*
15. Property Address*
16. City*
17. State*
20. Zip*
22. Home Phone Number*
23. Cell Phone Number
24. Work Phone Number
26. E-Mail*
28. Status of Building

    1. Existing
    2. Under Construction
    3. Proposed
30. Township (If Known)
31. Section Number (If Known)
33. Lot Size
    (Feet by Feet)
34. Acres
36. Type of Property

    1. Commercial

    1. Residential
38. Number of Bedrooms*
39. Garbage Disposal*

    1. Yes
    2. No
40. Water Softener *

    1. Yes
    2. No
41. Dishwasher*

    1. Yes
    2. No
43. Sewage Contractor (If Known)
45. Septic Location
    Please discribe the poposed location of the septic system
47. A soil analysis will need to be conducted by a representative of this office in order to determine the size of the drain field.
49. A backhoe may be needed for the soil analysis.
51. Applicant's Signature
53. Submitting this Application
    Please print and sign this form and include the $300 fee to:
    Floyd County Board of Health
    101 S. Main St.
    Charles City, IA 50616
Leave This Blank:


55. 1. Receive an email copy of this form.
56. Email address

    This field is not part of the form submission.

57. Submit Submit and Print

* indicates a required field