On-Site Sewage Facilities Permit Application

2. Kaufman County Development Services On-Site Sewage Facilities (OSSF) Application

4. APPLICANT INFORMATION
6. Type of Permit*
   -- Select One --MFG HomeCommercial HomeResidential HomeOther (specify below)
8. Other (specify type of permit)*
10. Name*
11. DL / ID*
13. Mailing Address*
14. Gate Code
16. City*
17. Zip Code*
19. Phone Number*
20. Email Address*
22. Site Address*
23. Gate Code
25. City*
26. Zip Code*
28. PROPERTY IDENTIFICATION
30. Property ID# (from County Appraisal District)*
32. Subdivision*
33. Phase*
34. Lot*
38. Single-Family Residence

40. Put N/A for ALL Single-Family Residence fields if you are applying for a Commercial Application.

42. Type*
44. SQ FT*
45. Bedrooms*
46. Bathrooms*
50. Commercial (Includes Multi Family)

52. Put N/A for ALL Commercial fields, if you are applying for a Single-Family Application.

54. Type*
55. SQ FT*
56. Number of Employees*
58. Installer Name*
60. Service Company Name*
62. OSSF #*
63. PH #*
67. Mailing Address*
69. City*
70. Zip Code*

72. The undersigned applicant certifies that all information supplied herein is true and correct to the best of my knowledge and no incorrect information was provided for purposes of obtaining a permit to construct an on-site sewage facility and applicant either owns and/or has authority to construct an on-site sewage facility on this property. Permission is hereby-granted to a designated representative of the licensing authority, Kaufman County Public Works Department, to enter said property for purposes of inspection, to determine compliance with applicable laws, standards, rules and regulations.

74. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
76. Electronic Signature*
77. Date*
    Date

81. AGENT INFORMATION

    COMPLETE THIS PAGE ONLY IF THE APPLICANT IS ACTING AS AN AGENT FOR THE OWNER.

83. OWNER IDENTIFICATION

85. Owner(s) Name

87. AGENT INFORMATION

89. Agent Name
90. Title
92. Physical Address
93. City, State
94. Zip Code
96. Mailing Address
97. City, State
98. Zip Code
100. Phone Number
101. Email Address
103. Date
     Date
104. DL / ID Number

106. The undersigned applicant further certifies that if they are acting as an agent for an entity identified above, specifically.

108. Check at least one that applies

     1. A partner (if the Owner is a partnership);
     2. An Officer of the corporation, association, Limited Liability Company, nonprofit corporation listed above; or
     3. An agent of the above entity, and by my duties in my above listed title I have such responsibility that have the authority to represent the policy and direction of the entity in this matter.

110. IF NONE OF THE ABOVE APPLY THEN YOU ARE NOT THE AGENT THAT SHOULD BE COMPLETING THIS APPLICATION. THIS APPLICATION MUST BE COMPLETED BY A PERSON WITH SUFFICIENT AUTHORITY LISTED ABOVE.

112. Electronic Signature Agreement

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
114. Electronic Signature
115. Date
     Date

117. SUBMIT APPLICATIONS: 101 N. Houston St., Kaufman, TX 75142 OR publicworks@kaufmancounty.net

119. If you check the box: Receive an email copy of this form. You’ll receive an e-mail from NoReplyCivicPlus.com.

Leave This Blank:


121. 1. Receive an email copy of this form.
122. Email address

     This field is not part of the form submission.

123. Submit

* indicates a required field