TETON AND PONDERA COUNTY HEALTH DEPARTMENT
Individual Sewage Disposal System Installation Permit

Installation For:____________________________________________Phone:_______________

Mailing Address:________________________________________________________________

Property Address:_______________________________________________________________

Legal Description:  Qtr Section_________Sec_________Twp__________Rge_______________

Type of Structure(s) to be Served:_______________New:___________Existing:_____________

Total Number:           Living Units:_______________Bedrooms:   _______________

NON-DEGRADATION: Provide information that this system is nonsignificant under the
non-degradation rules.

If subdivided Parcel, has sanitary restrictions been lifted?   Yes___________No______________

Method of water supply to the structure(s):  Well_____Cistern______Public______Spring______

Septic Tank Construction:   Concrete_________Other_________No. of Gallons______________

Drainfield: Type of tile_________Length of tile_________Effective Area_________(in square feet)

Describe Soil Depth to 8 Feet:______________________________________________________
     (soils data may be needed)

Depth To First Ground Water:__________________Percolaton Rate:__________________Min/in

Distance Of Installation From:  Property lines:  Front_________Back_________Side__________
                                               Foundation(s)______Well_____Surface Water_____Cistern_____


This system must be inspected before final covering. Please call the Health Department at
406-466-2150 or 406-278-3247 to schedule a time. If new or more restrictive conditions are found
before or during installation, the Sanitarian must be notified before progressing.

I CERTIFY THIS SEPTIC SYSTEM HAS BEEN INSTALLED ACCORDING
TO CURRENT SEPTIC SYSTEM REGULATIONS


Signature of Applicant:_____________________________________________________________

Signature of Installer/Contractor:_____________________________________________________


Plan Approved By________________________________________________Date_____________
                                                              Sanitarian

Installation Inspected By:__________________________________________Date_____________
                                                              Sanitarian

THIS PERMIT IS VALID FOR ONE YEAR FROM DATE OF ISSUANCE
Provide a diagram of the completed septic system. Show the location of the proposed/existing building, the septic system and the drainfield replacement area. Show distances from: wells, cisterns, surface water, water lines, slopes greater that 15%, roadways, property boundaries, and, if applicable, the 100 year flood plain.
NORTH
WEST
EAST
SOUTH
Draw a vertical view of the drainfield trench. Show depth of trench, depth of washed gravel, type of perforated pipe, indicate type of soil barrier used and amount of backfill.