State Of Kansas Division Of Environment Application For Sewer Extension Permit

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STATE OF KANSAS
DIVISION OF ENVIRONMENT
APPLICATION FOR SEWER EXTENSION PERMIT
The applicant hereby requests a permit for extension of sanitary sewers
in compliance with the requirements of K.S.A. 65-165 and K.S.A. 65-166.
Plans
and
specifications
submitted
must
comply
with
the
Kansas
Department of Health and Environment, Division of Environment, "Minimum
Standards of Design for Water Pollution Control Facilities."
APPLICANT DATA
1.
__________________________________________________________________
Name of Project (as it appears on plans)
City of Olathe
2.
__________________________________________________________________
Name of Applicant (Governmental Unit)
3.
__ -__ __ __ __ -__
__
__
__
Kansas Water Pollution Control Permit Number for the Wastewater
Treatment Facility which will treat the flow from this sewer
extension.
4.
__________________________________________________________________
Name the engineer or engineering firm responsible for inspection of
this extension.
In making application for a sewer extension permit, I hereby certify
that continuous engineering observation of the construction of the
proposed improvement, including building connections, shall be provided
in
accordance
with
Kansas
Department
of
Health
and
Environment
Regulation 28-16-55.
Signature:
______________________________
Authorized Official
Mary K. Jaeger, P.E.
Print Name:
______________________________
City Engineer
Title:
______________________________
City of Olathe
Mailing Address:
______________________________
P.O. Box 768
______________________________
Olathe, KS 66051-0768
______________________________

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