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General Permit No. GNEVOSDS09 - page 3 / 3

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_______   OSDS Size based on Fixture Unit Count: ______________________________________________

_______   Percolation rate/absorption rate: ________ (min/in) – Design rate/absorption rate: ________ (min/in)

_______   Depth to Seasonal High Groundwater: _______________ (ft)

_______   Type of absorption system (trenches, chambers mound etc): _______________________________

_______   Total OSDS Absorption area: ____________________________ (ft2)

_______   Total Absorption trench length: ____________________________ (ft)

_______   Number and length of trenches: ___________________Trench Separation ___________________

_______   Dosing Tank information – (if required): ________________________________________________

    _______________________________________________________________________________

    _______________________________________________________________________________

Certification:

‘‘I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a holding tank designed to assure that it complies with Nevada Division of Environmental Protection regulations.  I also confirm that records will be maintained at the project site from the start of activities, and that the site will be compliant. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fines for knowing violations.”

Printed Name of Applicant (Owner/Operator):_________________________________________________

Signature: ___________________________________________________ Date: ____________________

A copy of the permit will be mailed to you along with your discharge authorization.

Send completed form to:  

OSDS Program Coordinator

Nevada Division of Environmental Protection

Bureau of Water Pollution Control

901 S. Stewart Street, Suite 4001

Carson City, Nevada 89701-5249

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