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Intake Form
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Info@AZSoils.com
Call: 509-720-3933
Info@AZSoils.com
509-720-3933
AZ Soil Evaluations Intake Form
1) Project Information:
Project Name:
Project Description:
Sewer Availability:
Is Available
Is Not Available within 400 feet of the property
2) Site Location:
Subject Property Address:
City:
State:
Zip:
Cross Streets:
Parcel Number:
*
Subdivision:
Lot Number:
Recorded Deed Number:
Recorded Affidavit of Agreement to Encroach Number:
Latitude:
Longitude:
Site Code:
3) Property / Business / Project Owner:
Name:
*
Title:
Telephone:
*
Mobile:
Alt. Telephone:
Email:
*
Facsimile:
Address:
Country:
City:
State:
Zip Code:
4) Contact Person / Agent (If Different than the Owner):
Name:
Title:
Telephone:
Mobile:
Alt. Telephone:
Email:
Facsimile:
Address:
Country:
City:
State:
Zip Code:
5) Water Source: (check one below)
Water Company
Water Company Name:
Holding Tank (hauling water)
Private Well
Well Identification Number:
Shared Well
Shared Well Agreement Recording Number:
6) Existing / Required Permits:
List any county, state, or federal environmental permits issued for or needed by the facility, including any individual permit, Groundwater Quality Protection Permit, or Notice of Disposal that may have previously authorized or related to the discharge (check all that apply below):
Existing OSWTF
Description / Permit Number:
Other environmental permits required
Description / Permit Number:
Building Authority Permit
Agency:
Permit Number:
Flood Control Authority Permit
Agency:
Permit Number:
7) Applicant Certification:
READ CAREFULLY AND SIGN BELOW, this section is to be completed by the owner or contact person / agent identified in section 3 or 4 above.
:
By scheduling an inspection I understand I am granting authorization to enter my property to conduct an inspection. A report of inspection will be generated as a result of this inspection. By initialing below, I agree that the AZ Soils may send me a copy of its inspection report by e-mail to the
following email address:
(initials).
If there is a change in contact information, it is the responsibility of the permit holder to update AZ Soils.
I
, agree it is my responsibility to comply with all applicable statutes, rules, codes, ordinances and regulations for the work requested. Safety is the responsibility of the property owner or their agent. Request for inspection may be made by scheduling on our website AZSoils.com. To avoid additional inspection fees, be sure to include access information (e.g. gate code) and/or other special instructions or requests (e.g. meet inspector at site).
Signature:
Owner
*
Agent
*
Date:
Directions to site, special instructions, gate codes:
Submit & Schedule