_tslacKTora (.;ounty Health Dept.506 EAST VAN CLEVE STREETHARTFORD CITY, INDIANA 47348PHONE (765) 348-4317 FAX (765) 348-3041

Permit #---------

Date: -------------------

On-Site Septic System Permit ApplicationPlease check the appropriate spaces andfill in all additional information or insert N/A if not applicable.

Application for: New construction Repair or improvement of current system

If Repair, Reason for Repair: _ Damaged System_ Improper Const._ System Depth

Seasonal Water Table_ Improper Design_Undersized system

_Illegal Discharge_ System Age/Lack of Maintenance

Surface Failure

Owner Info: -----------------------Name Address City, State, Zip

Phone: or Fax: _

Site Info: -----------------=----:-:---:-::------c,-----------------Address Township/Section

Septic Contractor: _

# Of Bedrooms Jetted Tub (> 125 Gallons) _ Loti Acreage _

- Water Supply: Public Water Supply __ Proposed Well __ Existing Well: Size:__ Oepth: _

The Following Documents Are Required. Please Attach to Application.

A. Property Record Card/Legal Description of Property (assessor's office) [ ] R Floor Plan [ ]

C. System Design [J O. Location Map (auditor's office) [ ]

Septic System and Secondary Disposal DescriptionSeptic Tank Manufacturer: Septic Tank Size: gal.Dosing Tank Manufacturer: Dosing Tank Size: gal.

Distribution: __ Gravity Flow __ Flood Dosing Pressure Distribution

Disposal: __ Absorption field Sq.Ft. Trench Depth: ___ Gravelless Sq.Ft. Trench Depth: _

At-Grade Basal Area: _Sand Mound Basal Area: _

Perimeter Drain: Size: ----- Depth: _ Stone: _

I, the undersigned, do now affirm under penalties of Perjury that the foregoing information and/or representations are true tothe best of my Imowledge and do now certify that this facility will be installed to meet State and local requirements of theHealth Department of Blackford County, Indiana.

Date: _ Signature of property owner: _

Date: _ Signature 0 f contractor: -----------------•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••System Approved: System Denied: _ Signed: _--,-_-,.-::,-------,-- __ ---:-:-:---;-;_;::;-_-:-;-;-

Registered Environmental Health Specialist

Corrections Required (See Reverse Side) Date: _

..,

BLACKFORD COUNTY HEALTH DEPARTMENT506 E. VAN CLEVE STREET

HARTFORD CITY, INDIANA 47348TELEPHONE 765-348-4317

The Blackford County Health Department has recently been informed there is a type ofsoil called recessional moraines, which may be unsuitable for on-site septic systems.There are serious problems with the proper function of on-site sewage systems installedin these soils. Blackford County has some of these types of moraines located within thecounty.

The usual soil analysis methods currently used by soil scientists will not detect themoraine soil. A more extensive soil analysis consisting of soil pits and mechanicalanalysis of individual soil profiles will be required to determine if moraine soils arepresent. If lab results confirm the presence of>50% clay, a modified permeability testwill be required.

The Blackford County Health Department will recommend the septic system suitable foreach site. These recommendations are based on the soil analysis and sized according tonumber of bedrooms in the house. If testing results in the presence of selected moraines,the site may be rejected for an on-site septic system.

Blackford County Health Department will continue its policy of determining the type ofseptic system for each site by using the information obtained through soil analysis. If adefinite area of moraine soil is located, additional tests will be necessary to determine ifthe location is suitable for an approved septic system.

Is should be noted, the Blackford County Health Department recommendations forinstallation of septic systems follows the guidelines of the Indiana State Board of Health.No guarantees to the actual performance of septic systems installed in Blackford Countyar arranted or implied.

n~riles, R.E.H.S.

I have read the above and fully understand the information presented to me on thisDate and agree to the terms and specifications required by the BlackfordCounty Health Department in accordance with rules established by the Indiana StateDepartment of Health to install an approved septic system on my property.

Signature of Property Owuer _

SEPTIC SYSTEM LOCATION PLAN AND DRAWING

Name: ---------------------------------------------------------------Site Address: ------------------------------------------------------------Include all distances, including property lines, and distances to potable water supply.

SKETCH

,.

PLOT PLAN CRITERIA FOR RESIDENTIALSEWAGE DISPOSAL SYSTEMS

1. LOT SIZEIDIMENSIONS/CONFIGURATION

2. N, S, E, W DIRECTIONS

3. LOCA nON (PROPOSED) OF HOUSE, OTHER STRUCTURES, DRIVEWAYS, ETC.

4. LOCATION (PROPOSED) OF ALL PARTS OF RESIDENTIAL SEWAGE DISPOSALSYSTEM

5. ALL SLOPE DIRECTIONS

6. SHOW DRAINAGE CHARASTERISTICS OF LOT AND ADJOINING LANDSCAPE IFIT HAVE AN IMP ACT ON THE SYSTEM

7. SHOW ALL APPLICABLE SEPARATION DISTANCES AS OUTLINED IN lAC 6-8.1(a), (b) and 37 (a)

[] well, water lines on this lot and neighboring lots within 100 feet[] buildings and other structures[] Lot lines (5 feet)[] streams, ditches, drainage tile (10-25 feet)[] bodies of water (50 feet)

8. SHOW LOCA nONS OF ALL UTILITIES AND OTHER EASEMENTS9. LOCA nONS OF ALL BORING SITES BY THE SOIL SCIENTIST