Kansaswater Pollution Control Permit Foragricultural Andrelated Wastes Permit Application
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10Kansas Water Pollution Control Permit for Agricultural and Related Wastes
Permit Application
Livestock Waste Management Program
Department Use Only
Facility ID No.
Instructions: PLEASE PRINT. Complete and provide
all information as requested. Attach all drawings and
Certification No.
plans to this application.
If you need assistance
Permit No.
completing this form, call (785) 296-6432 or your local
Date Permit Application Complete:
KDHE District Office. Mail completed application to:
Permit Fee:
Yes
No
LIVESTOCK WASTE MANAGEMENT SECTION
KDHE - BUREAU OF WATER
1000 SW JACKSON STREET, SUITE 420
TOPEKA, KS 66612-1367
If a registration form has been submitted to KDHE within the previous eighteen months, only pages 1
through 7 and not previously submitted portions of Appendix 3 need to be completed. Any information
from pages 5 or 7 submitted with the registration does not need to be resubmitted unless changes need to
be noted.
NOTICE: Failure to provide all required documentation at the time of submission of this permit application will
result in the entire permit package being returned to the applicant for completion.
FACILITY IDENTIFICATION
1. Name of Applicant: _______________________________________________
Date:
Name of Property owner(s)
:
(if different from Applicant)
2. Name of Firm or Facility:
3. Mailing address:
City: __________________________________________ State:________________ Zip:
4. Facility address (if different):
City: __________________________________________ State:________________ Zip:
5. Business Telephone No.:___________________________ Home Telephone No.:
Cellular Telephone No.:____________________________ Fax No.:
E-Mail address:
Applicant hereby makes application to the Kansas Department of Health and Environment in conformance with K.S.A.
65-171d et seq. and K.A.R. 28-18-1 through 17, and/or 28-18a-1 through 33.
KDHE BOW LWMS Permit Application form rev 4/7/2015
Page 1 of 10
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