Recpt



|Receipt |      |

|Date |      |

|AMT. |$      |

|Ini. |      |

[pic] FORT WAYNE-ALLEN COUNTY DEPARTMENT OF HEALTH

APPLICATION FOR CONSTRUCTION PERMIT

FOR ONSITE SEWAGE SYSTEMS

COMMERCIAL ESTABLISHMENTS & INSTITUTIONS

(This form is to be used for all installations except for a 1 and 2 family residence.)

|NAME OF APPLICANT |                                                        |TELEPHONE |                          |

|MAILING ADDRESS |                                    |CITY |                |STATE |      |ZIP |           |

|NAME OF PROPERTY OWNER |                                              |TELEPHONE |                |

|PRESENT ADDRESS |                                    |CITY |                |STATE |      |ZIP |           |

|I hereby request permits to construct an Onsite |

|Sewage System at the following location: |

|NUMBERED ADDRESS OF SITE: |                                                                                      |

|CITY |                                              |STATE |                |ZIP |                | |

|LOT NUMBER |           |SUBDIVISION NAME |                                         | |

|SECTION |           |TOWNSHIP |                          |(NAME) |

|TYPE OF SYSTEM PROPOSED |                                                                                      |

|(Gravity fed, flood dosed, elevated mound, at-grade. . . .) |

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

|NEW INSTALLATION |REPLACEMENT |ALTERATION |REPAIR |(CHECK ONE) |

|TYPE OF ESTABLISHMENT |                                                                            | |

|LOT SIZE |                     |(DIMENSIONS) |                |(ACRES) |

|CLOSEST DISTANCE FROM SEPTIC OR DOSING TANK TO: (FEET) |

|WELL |           |2.) STRUCTURE |           |3.) PROPERTY LINE |           | |

|NAME OF TANK MANUFACTURER |                                                                                 |

|LIQUID CAPACITY: |1.) SEPTIC |           |2.) DOSING |           |(GALLONS) |

|DISTANCE TO NEAREST CITY SEWER & CITY WATER |                                                                  |

|ESTIMATED MAX. NO. OF PERSONS TO BE SERVED |                                                        |

|ESTIMATED MAX. NO. OF GAL. OF WASTES TO PASS THRU SYSTEM PER DAY, |                                              |

|(An itemized estimate of the max. daily sewage flow must be submitted with plans. Every possible source of wastewater must be included and estimate |

|must be properly certified.) |

|WATER SUPPLY (Specify) Private well or Public Water supply |                                                                  |

|PRIMARY TREATMENT: Septic tank: Manufacturer |                               |Liquid capacity |           |gals |

| |

|Remarks: _______________________________________________________________________ |

|SECONDARY DISPOSAL: Distance to: nearest well |___________ ft. / to structure ___________ ft./ to property line ___________ ft. |

|(1) ABSORPTION FIELD: Total length of tile |      |ft. Width of absorption trenches _________ in./ Total trench bottom area ______ sq. ft. |

|(2) Other: |                                                                                                               |

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

SUBMIT LOT LAYOUT OF RESIDENCE. Show location of septic tank, dosing tank absorption field or other secondary system, well, well pump, tile lines, sewers, drains, drainage ditches, plumbing, driveways, roads, property lines and rough floor plan of establishment with sufficient label and dimensions to identify and locate all items. Draw to scale and show scale. A LEGAL DESCRIPTION IS ALSO NECESSARY.

Permit Fee Schedule

Permit Type (Payable to Fort Wayne - Allen County Department of Health) Fee

Septic Construction Permit (New or Replacement) $175.00

(Must obtain prior to the commencement of any excavation, construction, modification

or addition to any existing or new private sewage disposal system.)

Septic Construction Permit (Alteration, Repair or Privy) $75.00

(Must obtain prior to the commencement of any alteration, repair, modification,

or addition to any existing private sewage disposal system that does not involve

the replacement or modification of the soil absorption field, or permitted discharge system.)

I hereby certify that facilities at the above location will be installed in compliance with Allen County Code Title 10 –4.5, and as outlined in this application. I further certify that to the best of my knowledge all information contained in this application is correct. I understand it will be necessary for a representative of the Fort Wayne – Allen County Department of Health to visit my property during normal business hours to inspect the construction of my system and I consent to this inspection. I further understand that this permit will expire in one year from the date of issue if the system has not been substantial completed by that time.

| |                                              |

|SIGNED | |

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