Get Manitoba Ejector Exemption

Date Signature Applicant Application Fee plus 5 GST GST Registration No. R107863847 Retain a sewage ejector 3-20-9 150. 00 7. 50 157. 50 Cheque payable to Minister of Finance FOR DEPARTMENT USE ONLY Application Reviewed and System Inspected by Certificate of exemption recommended EO No. Comments Latitude Longitude Personal information is collected under the authority of The Environment Act the Onsite Wastewater Management Systems Regulation and will be used for administration and enforcement purposes. ONSITE WASTEWATER MANAGEMENT SYSTEMS REGULATION Application for Certificate of Exemption to retain a sewage ejector system upon transfer or subdivision of land APPLICANT S NAME Mailing Address City/Town Phone Postal Code Home Business Cell Fax Email Legal Description Section Township Range / Lot and Block No / Street Address Municipality Request for Transfer of land Subdivision of land Property size hectares/acres Is sewage ejector connected to more than one single family dwelling Yes Was a variance to allow the sewage ejector to be located on 5 acres for a farm subdivision previously obtained Yes - attach copy of letter No Sewage Ejector Location Information Is system located on soil class 6 or 7 or unimproved organic soils Provincial Park Crown Land Sensitive Area Nearest Property Boundary Distance from sewage ejector to m/feet Watercourse Cut or Embankment Market Garden Well Boundary of City / Town Village Year existing sewage ejector system was installed A site plan must be submitted with this application I certify the above information is correct. Date Signature Applicant Application Fee plus 5 GST GST Registration No* R107863847 Retain a sewage ejector 3-20-9 150. 00 7. 50 157. 50 Cheque payable to Minister of Finance FOR DEPARTMENT USE ONLY Application Reviewed and System Inspected by Certificate of exemption recommended EO No* Comments Latitude Longitude Personal information is collected under the authority of The Environment Act the Onsite Wastewater Management Systems Regulation and will be used for administration and enforcement purposes. Information collected is protected by the privacy provisions of The Freedom of Information and Protection of Privacy Act. If you have any questions contact the Access Privacy Coordinator Box 85 200 Saulteaux Crescent Winnipeg MB R3J 3W3 1-204-945-4170. White Manitoba Conservation OWMS Application for Certificate of Exemption MG- Canary Applicant Page 1 of 1 Applicant s Name Sample Drawing SITE PLAN DIAGRAM The site plan must include the following information 2. Location of sewage ejector system and distances to any of the following Inhabited buildings Water service pipe Property boundary N. 00 7. 50 157. 50 Cheque payable to Minister of Finance FOR DEPARTMENT USE ONLY Application Reviewed and System Inspected by Certificate of exemption recommended EO No* Comments Latitude Longitude Personal information is collected under the authority of The Environment Act the Onsite Wastewater Management Systems Regulation and will be used for administration and enforcement purposes. Information collected is protected by the privacy provisions of The Freedom of Information and Protection of Privacy Act.