Trinity River Authority of Texas LAKE LIVINGSTON PROJECT Serving as an agent of the Texas Commission on Environmental Quality P.O. Box 360                A/C 936 Livingston, TX  77351    365-2292 APPLICATION FOR ON-SITE SEWERAGE FACILITY

I hereby make application to install and operate an on-site sewerage facility or holding tank within the 2,000 foot Water Quality Zone as designated by TAC Regulation 285.3 of the Texas Commission on Environmental Quality.

NAME OF APPLICANT______________________________________________________________
                                          (Last)                               (First)                            (Middle)

HOME ADDRESS__________________________________________________________________ 
                                 (Street, P.O. Box)              (City)                (State)                (Zip Code) 

HOME TELEPHONE NO.__________________ BUSINESS TELEPHONE NO._________________

LOCATION OF PROPOSED CONSTRUCTION:

SUBDIVISION____________________  SECTION__________  BLOCK___________  LOT_______

DESCRIBE LOCATION IF NOT IN SUBDIVISION_________________________________________

_________________________________________________________________________________

TYPE OF CONSTRUCTION__________________________ COMMERCIAL (    )  DWELLING (    ) 

NO. OF BEDROOMS___________________ NO. OF BATHROOMS__________________________ 

GARBAGE DISPOSAL__________ WASHING MACHINE__________ DISHWASHER____________
___________________________________________________________________________________ 

SEPTIC SYSTEM:        PROPOSED (    )    EXISTING (    )                          HOLDING TANK (    ) 

If existing system complete the following items: 

SIZE OR DIMENSION OF TANK_________________________________________________________ 

DRAINAGE:      A.  WIDTH OF DRAINFIELD DITCH_________________________________________

                        B.  TOTAL LENGTH OF DRAINFIELD_______________________________________

D.   DRAINFIELD DISTANCE FROM WATER’S EDGE (131 ft.  MSL)
_______________________________________________________________________ 

Authorization is hereby given to the Trinity River Authority of Texas, Texas Department of Health, and the Texas Commission on Environmental Quality or their agents or designees, singularly or jointly, to enter upon the described property for the purpose of making soil percolation test, inspecting septic systems or for any reason consistent with the water quality programs of the Trinity River Authority of Texas, The Texas Department of Health, or the Texas Commission on Environmental Quality.

________________________________________                                   _________________________
Signature of Applicant                                                                         Date