MONTANADEPARTMENTOFENVIRONMENTALQUALITY/LOCALGOVERNMENTJOINTAPPLICATIONFORM

PARTI.GENERAL DESCRIPTION ANDINFORMATION

1.Name of proposed development

2.Location: City and/or county

Legaldescription:NE1/2N1/2

of Section

3.Is concurrent review by localgoverning body and DEQ requested?YesNo

4.Type of watersupply system

Individual wellIndividual cistern

Individualsurface watersupply orspringShared well (2connections)

Multiple-user watersupply system(3-14connectionsandfewerthan 25 people)Serviceconnection tomultiple-usersystem

Serviceconnection topublicsystemExtension of public main

Newpublicsystem (15 or moreconnections orserving25 or more people)

5.Type of wastewatertreatment system

Individualwastewatertreatmentsystem

Number ofbedrooms (3 bedroomswill be usedifunknown)Shared wastewater treatment system(2 connections)

Multiple-usersystem(3-14connectionsandfewerthan 25 people)Serviceconnection tomultiple-usersystem

Serviceconnection topublicsystemExtension of public main

Newpublicsystem (15 or moreconnections orserving25 or morepeople)

6.Name of solid waste (garbage) disposal site

7.Nondegradation

YesNoIs informationincluded whichsubstantiatesthattherewill beno degradation ofstatewatersorthatdegradation will benonsignificant?

YesNoIf not, haveyouenclosedan Application to Degrade?

8.DescriptiveData

Numberoflots orrentalspacesTotal acreage in lots being reviewedTotal acreage in streetsorroads

Totalacreageinparks, openspace,and/orcommon facilitiesTotalgross acreage of subdivision

MinimumsizeoflotsorspacesMaximum sizeoflotsorspaces

10.Providethe followinginformation regarding the development.Current land use

Depthto ground wateratthetime ofyearwhen watertableisnearest tothenaturalgroundsurfacewithinthedrainfieldarea

Depthtobedrock or otherimpervious materialinthedrainfieldareaExisting zoning or other regulations

11.Include thefollowingattachments,ifapplicable.

YesNAAn overall development planindicatingtheintent for the development oftheremainderofthetract, if a tract of landisto be subdividedin phases.

YesNADraftsofany covenants and restrictionsto be includedin deedsor contractsfor sale.

YesNADrafts of homeowners' association bylawsandarticles of incorporation,ifapplicable.

(Submitting a draft copyofa homeowners’associationbylawsandarticles of incorporation is adequatefor DEQtoinitiateand completeitsreview ofsanitaryfacilities,but a copyofthefullyexecuteddocumentsmust be submittedbefore DEQcanissue finalapproval.)

Iunderstandthat a personmay notdisposeofanylotwithin a subdivision,erectanyfacilityforthesupply of wateror disposalofsewage orsolid waste,erectanybuilding orshelterin a subdivisionthatrequiresfacilitiesforthesupplyof wateror disposalofsewage or solid waste, or occupy anypermanentbuildings ina subdivision untilthereviewingauthorityundertheSanitationin SubdivisionsAct has issueda certificate of subdivisionapprovalindicatingthatthesubdivisionisnotsubjecttosanitaryrestriction, unlessthesubdivisionisexempt from theSanitationin Subdivisions Actunder76-4-125,MCA.Iunderstand that apersonmaynotconstructoruse a facilitythatdeviatesfromthecertificate of subdivisionapprovaluntil the reviewingauthority has approved thedeviation.

I designateas my representative for purposesof this

application.

Designatedrepresentative,if any (e.g.,engineer, surveyor)

Name:Phone:

Address:

Owner

Company,Street or P.O. Box, City,State,ZipCode

Name:

Signature of ownerPrint name of owner

Address:

StreetorP.O. Box,City,State,ZipCode

Date:Phone:

(The statementmust be signedby theowneroftheland proposedforsubdivision ortheresponsibleofficer of thecorporation offeringthesameforsale.)

Notice: Thestatutorytimeframeforeachreviewis 60 days.Resubmittal of deniedorincompleteapplicationsrestartsthetimeframe.TheestimatedtimefortheDEQtoactona completesubdivision applicationis 10 days forsubdivisionsreviewed bya local departmentof health undercontract totheDEQ.Localhealth departmentsreviewsubdivisions within50 days ofreceiptof a completeapplication.During non-peaktimes, a reviewmaytake25to45days.For peaktimes,thereviewmaytake45to60 days.