SUBDIVISION APPLICATION - Eastern Idaho Public Health District

Application for Subdivision/LandDevelopment ReviewFEES:Central Water SewerPlats:$$$$$$$$$$On-Site Sewage Plats orParcel Splits:$$$$$$$$$$Developer/Applicant Name:________________________ Phone #:_____________ Fax#:_________________Mailing Address:Street/P.O. Box City State ZipE-mail address:_____________________________________________________________________________Name of Subdivision:________________________________________________________________________City: _____________________________ County:________________________________________________Location of Subdivision:Legal Description:Township __________ Range _________ Section __________ ¼ Section___________Parent Parcel Number of Site__________________________________________________________________Property Owner (if different):________________________ Phone #:_____________ Fax#:________________Mailing Address:Street/P.O. Box City State ZipE-mail address:_____________________________________________________________________________Engineer:Name Phone License #Mailing Address:Street/P.O. Box City State ZipE-mail address:________________________________________________________ Fax#:_______________Surveyor:Name Phone License #LandAcres______________ Total # Lots _____________ Buildable _____________ Non-buildable _____________Minimum Lot Size in Acres__________________ Average Lot Size in Acres__________________WaterType of Water: Private Water Shared Well (Non-Public) Public Water SystemWater Supply: Surface Water Ground WaterIf Public Water System, services provided by:____________________________________________________rev. 06/11/10

SewerType of sewage disposal system: Individual Septic Municipal Sewer Central Septic &/or LSAS Septic (>2 dwellings or 2500gpd)If municipal sewer, services provided by:______________________________________________Type of Plat: Residential Commercial IndustrialLocation: City County Impact ZoneDirections:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________StormwaterType of Disposal: Shallow Injection Wells (drywells) Grassy Swale N/AService for: Street Only Street and Lots Other N/AChemical/Hazardous Materials(Commercial or Industrial Subdivisions Only)Are chemicals or petroleum products likely to be stored/handled/used at these sites? Yes No N/AIf yes, please explain: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Applicant Signature:_____________________________________ Date: _________________This Section for Official Use onlyIf on-site sewage disposal systems used; date predevelopment meeting held with District (if required):Date of Meeting: _________________Application DateSubdivision #File/Document # __________________Instrument #Fee $ ____________Date__________Fee $ ____________Date__________Receipt #_______________________Receipt # _______________________Sanitary Restrictions: In-Force Satisfied See Attached LetterEHS Signature:_____________________________________ EHS #:_______________Date:______________rev. 06/11/10