TOWN OF
APPLICATION FOR APPROVAL OF
SEWAGE DISPOSAL SYSTEM
Carl
Irwin, SANITARY CODES OFFICER - Phone
826-3436
Fee of $ 20.00
(twenty-dollars) to accompany application.
Parcel Tax Map No. Date:
*Items 1 thru 4 to be filled
out by Applicant or Contractor*
- Applicant data:
Name: (print)
Address:
Telephone: Daytime: Evening:
Location of Property/911 Address (if different than above)
- Contractor data:
Name:
Address:
____________________________________________________________________
Type of structure or facility:
(example: single family
residence, cattle barn, retail store )
No. of rooms: No. of bedrooms:
- Description of system and
work to be done (in addition to information shown on attached sewage
disposal diagram. See attached example and instructions):
Liquid capacity of septic tank: ______ (gals.)
Signature of Property Owner or
Contractor:
*Items 5 thru
7 to be filled out by Sanitary Codes Officer*
- Soil Evaluation Data:
NOTE: The separation distances will be as required
in Section 8 (1) of the Town of
- Soil: Clay Loam Sand Rocky
- Surface: Flat Sloping Steep
- Soil Percolation Test:
Date Administered:
Time in Minutes for one (1) inch
Remarks:
Signature of Town Sanitary Codes Officer Date
INSPECTION REPORTS: TO BE COMPLETED BY THE SANITARY CODES FFICER
Date of Inspection:_________ Inspected
by:________________________________________
Remarks: ____________________________________________________________________
Date of Inspection:_________ Inspected
by:________________________________________
Remarks:
____________________________________________________________________
Date of Inspection:_________ Inspected
by:________________________________________
Remarks:
____________________________________________________________________
SEWAGE DISPOSAL DIAGRAM - INSTRUCTION
The septic system diagram must include the following information:
- Distance of waste outlet from building reference corner ____
- Distance from house to septic tank ____
- Size of septic tank (gallons) ____
- Distance from septic tank to distribution box ____
- Length of absorption field lines ____ or dimensions of seepage pit ________
- Number of absorption field lines ____
- Distance from absorption field or seepage pit to nearest side lot line ____
- Distance from absorption field or seepage pit to nearest front/back lot line ____
- Distance from absorption field or seepage pit to any water course or feature ____
- Distance from absorption field or seepage pit to nearest water source (e.g: well) on owner’s property or adjacent property ______
- Dimensions of all lot lines ____
- Dimensions of all structures ____
This diagram is an example only. The
plot plan accompanying your application must include the information listed in
the preceding Instruction as it applies to your system.
The actual system design will
depend on such variables as soil, number of bedrooms etc. Your contractor and
the Sanitary Codes Officer will be able to offer information on your particular
situation and its requirements.
SEWAGE DISPOSAL DIAGRAM
Please show a diagram of your proposed system in the space below.
A sample diagram is attached, as well as a list of data that must be shown on your diagram.
TAX MAP # NAME:
SEWAGE DISPOSAL SYSTEM
CERTIFICATE OF APPROVAL
TOWN OF
Parcel Tax Map No. DATE:
PROPERTY OWNER_________________________________________________
LOCATION OF PROPERTY___________________________________________
_______________________________________________________________________
CONTRACTOR'S NAME AND ADDRESS ______________________________
_______________________________________________________________________
Receipt of this certificate indicates that the applicable provisions of
the Town of
SIGNATURE________________________________________
Sanitary
Codes Officer
DATE SIGNED_______________________________________