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General Permit No. GNEVOSDS09 - page 1 / 3

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Nevada Division of Environmental Protection

Bureau of Water Pollution Control

Onsite Sewage Disposal System (OSDS) Application

             General Permit No. GNEVOSDS09

Note: Please consult with local or state agency to confirm the proposed method of sewage disposal at your location is acceptable; some restrictions may apply. Please refer to NRS 445A & NAC 445.

Applicant: (Agency/Person responsible for the OSDS System)

Name: _______________________________________________ Phone: ____________________________

Address: ______________________________________________________Fax: ___________________

City: __________________________________________ State: _________________ Zip: _______________

Site Location(s): If more than one, please attach a legal description of each site.

Project Name_____________________________________________________________________________

Project Address: __________________________________________________________________________

City: ________________________________ County: ____________________ State______ Zip: __________

Latitude:   ___________/ __________/ __________        Longitude:  ___________/ ________/ ____________ Deg.         Min.        Sec. Deg.           Min.           Sec.

Township_______________    Range________________  Section__________________

Engineering Firm Information

Name: ________________________________________ Phone: _______________ Fax_________________

Contact Person: ___________________________________ email : _________________________________

Address: ________________________________________________________________________________

City: __________________________________________ State: _________________ Zip: _______________

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