Request for Authorization/Permit to Construct an On-Site Sewage Treatment System
Please read the following instructions carefully before filling out form
* Indicates Required Field
If you provide an email address, the application and payment information will be emailed to you.
If you are a Certified Installer, you must use your Certification Number to ensure correct billing.
It is recommended that a copy of the form 641-581 Report for On-site Sewage Treatment be available to complete the property information and legal description.
Please note, entering incorrect property information may cause delays in the processing of your request due to incorrect ES assignment.
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REQUESTER INFORMATION Certification Number
Requester's First Name * Requester's Last Name *
Contact First Name * Contact Last Name *
Address * City * State Zip *
Contact Phone * Fax Email
PROPERTY INFORMATION
Current Property Owner First Name * Last Name *
Property Address * County Where Property is Located *
City * State OK Zip * Phone
Subdivision Lot Block
Section * Township * Range *
REQUESTED SERVICE(S)
FEE
$347.89 $208.73
Type of On-Site Sewage Treatment System to be installed

$278.28
Your Total Fee is