Appendix F: Standardized On-Site Wastewater Disposal Permit Application

On-Site Wastewater Disposal Permit Application

Permit number: Date of permit:
First name (owner): Last name (owner):
Company name:
Street address (owner):
City (owner): ZIP code (owner):
Street number (site): Street (site):
City (site): ZIP code (site): ID #: **
Section: Township: Range:
Latitude (optional): Longitude (optional): Multiple systems
Type of permit new replace repair
Use of facility: 1 or 2 family dwelling subdivision school restaurant
  mobile home park small commercial large commercial daycare center
  campground hotel / motel medical facility / nursing home other
Subdivision name: Installer name:
Soil Scientist name: Date of inspection: Inspector:
Soil conditions at construction: dry moist wet
Water supply: public pond well cistern spring
Site slope (average %): Soil series name:
Limiting layer: compact glacial till bedrock muck impermeable clay
  coarse sand or gravel marl fragipan none
Depth to limiting layer (in.): Depth to mottling (in.):
Pretreatment: septic tank none
Treatment: aeration plant constructed wetlands lagoon intermittent sand filter
  recirculating sand filter slow sand filter none
Distribution: gravity flood dose pressure distribution none
Disposal: absorption field alternating field at-grade elevated sand mound
  bed chamber gravelless trench holding tank
Design flow (gal./day): Total tank(s) volume (gal.):
Absorption field (sq. ft.): Trench bottom depth (in.):
Dosing frequency (times/day): Depth to drain (in.):
Drain installed Watertight tested Garbage grinder Soil evaluation Permit granted
Comments:

Previous System Information

Previous pretreatment: septic tank none
Previous treatment: aeration plant constructed wetlands lagoon intermittent sand filter
  recirculating sand filter slow sand filter none
Previous distribution: gravity flood dose pressure distribution none
Previous disposal: absorption field alternating field at-grade elevated sand mound
  bed chamber gravelless trench holding tank
  cesspool direct discharge irrigation evapotranspiration
  privy other
Previous permit number: Original system date (year):
Reasons for failure: damaged system excessive water use groundcover lacking illegal discharge
(rank one and two, with improper construction improper design lack of maintenance leaky tank/plumbing
one as the most limited space limiting soil layers location of structures system age
significant problem.) system depth system wetness treatment missing undersized system

Multiple System Information

Number of systems:
Systems installed:
Lot numbers / Additional notes:

Check the most descriptive one unless otherwise indicated

** Usually parcel or lot number. Consult with sanitarian for further instruction.

Form is represented as accurately as possible. Some changes have been made to allow publication on the World Wide Web.

An Evaluation of On-Site Technology in Indiana: Table of Contents