Letter Head of City/Municipality

Septic Tank Permit Application Form

1. APPLICANT DATA
Name: Israel G. Orquia
Company: Villages Water Supply System Inc. (FCI-Dapdap)
Address: Block 8 Lot 14 , Phase 4 , Mansfield Residences , Brgy. Sto. Domingo , Angeles City, Pampanga
Telephone: _________________________________Fax: _________________________
2. TYPE OF APPLICATION 3. SEWAGE FLOW
Residential: ________Commercial: __*_______ Average water usage : 3812.50 cu.M./month
New construction: _____*____ Remodel: ___________
Nu Number of people in residence: 287
4. SEPTIC TANK DESIGN INFORMATION:
S Size: 2.00M X 1.50M X .90M
Material Used: TTotal Volume: 2,700 liters
Concrete (poured in place): ____*____ Number of compartments: ______3____
Concrete (precast): _______ Hollow Blocks: __*______NName of Manufacturer (if any):
Plastic: _______ Fiberglass: ________ Other: ________ _____________________________________________________

N Note: Use of steel, wood or other materials that may degrade in the soil is prohibited
5. PLOT PLAN OR SKETCH.In the box below, please show North arrow, building locations, septic tank locations,
streets, driveways, cut banks, water lines and any other feature of the property that may effect the septic tank installation.
(Use other sheet if space is not enough)
Setback Table
Septic tanks must be adhere
to the following setbacks:

Well: 25 meters
Lake: 25 meters
Stream/river: 25 meters
Flood plain: 25 meters
Water line:3 meters
Structure:1 meter
Property line:1 meter
Cut Bank: 1 meter
(For Official Use Only)

____________________________________________________
SANITARY INSPECTOR

____________________________________________________
RHP/MHO

Recommending Approval:

____________________________________________________
SANITARY ENGINEER

Approved by:

_____________________________________________________
PROVINCIAL HEALTH OFFICER II
_____________________________________________________
Issued Date: __________________________________
Final Inspection: _____________________________
Comments: _______________________________________________
______________________________________________________________

CERTIFICATION

I hereby certify that the above information is true and correct and the proposedwork will be done to meet the requirements of
the Office of the Building Official and Sanitation Division of the Health Office of the above Local Government Unit.

Applicant name: _________________________________________Signature:_________________________________________Date: __________________________