Application for On-Site Sewage Facility (Ossf)

Williamson County & Cities Health District WCCHD Use Only (WCCHD) Application No. ______-______Environmental Health Services 303 Main Street Date: ______Georgetown, Texas, 78626 512-943-3620 Fees:______Initials:______512-930-3110 Fax ______APPLICATION FOR ON-SITE SEWAGE FACILITY (OSSF) Print out and complete for submittal in person or via mail to below address ***Application valid for one year from date of application***

Property Owner’s Name: Last First M.I. Current Mailing Address: Number & Street City State/Zip Daytime Telephone No.: (____)______Other Phone No.: ( ) Email: Site Address: Number & Street City State/Zip Daytime Telephone No.: (____)______Other Phone No.: ( ) Subdivision: Phase: ______Lot: ______Block: ______Legal Description if not in subdivision (a copy of a survey drawing is required if lot has not been platted): Acreage: Survey Name: Abstract Number: Single Family Residential: ______# Bedrooms (rooms w/ closets) Living Area (ft2) Commercial/institutional (anything other than single family residential): No. of Employees: _____ Type of Use: ______Size of building: ______Commercial applications must complete a commercial use questionnaire. Source of water: Well/Cistern (check if a well is present or proposed) Public Water, Name of Company Other Other: Low Flow Fixtures In Edwards Aquifer Recharge Zone New Repair Site Built Home Mobile Home Commercial/Institutional Flood plain

Attach map with directions to site: I certify I am the property owner/ designated agent and the above statements and information are true and correct. This is a permit application only and does not guarantee that a permit to operate an OSSF will be granted. Construction of the system can not begin until all planning material has been submitted and an authorization to construct an OSSF is issued. The property must be accessible (no locked gates) at all times. To prevent additional fees, the application identification tag must be posted at all times of construction and for inspections. Fees will be due to reschedule inspections and to upgrade to an engineered system or a system requiring routine maintenance.

Signature: ______Date: ______revised 1/4/16

Environmental Health Services  303 Main Street, Georgetown, TX 78626  512-943-3620  Fax: 512-930-3110 Visit your public health department online at www.wcchd.org