Clean Water Program Application Form:

Septic Systems

Please complete the following application, and forward to:

UpperThamesRiver Conservation Authority

1424 Clarke Road, London, ONN5V 5B9

E-mail:

Fax: 519-451-1188

Personal Information

Name:
Address:
Town/City, Postal Code:
Telephone:
Fax:
911 Number:
E-Mail:
Do you have a Farm Business Number (FBN) (write Yes or No)

Project Location

Municipality/Township: / County:
Lot: / Concession:
Workable Acres Farmed - Own: / Rent: / TOTAL:

To be completed by CWP staff

Coordinates: X / Y
Conservation Authority: Upper Thames River / Long Point Region / Grand River

Please put an “X” beside the section(s) that you are applying for.

Conventional system
Non-traditional secondary or tertiary treatment system
(must be an Approved Treatment Unit by the Ontario Building Code)
Holding tank
Note: Non-traditional systems or systems over 10,000 litres require Ministry of the Environment approval through the Water Resources Act. All systems must be installed by a licenced contractor. All works must be completed in compliance with Part VIII of the Ontario Building Code.
Describe the age and present condition of your system and how it impacts surface and/or groundwater quality:

General Information

Estimated cost of project:
Estimated project completion date:

Additional Information

Please provide any additional information or comments.
I acknowledge that the Clean Water Program representative can verify that I have an Environmental Farm Plan that is deemed appropriate.
I had my EFP peer reviewed in the County of:
Signature:
Date:

Site Plan

Show existing site features and proposed best management practices. Include farm buildings, and the distance to: dug wells (>60 m / 200 ft minimum), watercourses, drilled wells (water-tight casing 6 m deep, >30 m / 100 ft minimum), lake front, field tiles, building, property boundary (3 m / 10 ft minimum), driveway or parking area, roadside drainage ditch, catchbasins, and wetlands.

Septic Systems 1