Onsite Sewage Disposal Systems Application For Site Evaluation Application No.Application No.Date ReceivedDate ReceivedCountyCountyTO BE COMPLETED BY APPLICANTApplicant's NameApplicant's NameOwner's Name (if different)Owner's Name (if different)Present AddressPhoneEmail Location of PropertyAcreage / Lot #ATTACH TO THIS APPLICATION THE FOLLOWING 1. Location map to reach site. 2. Site drawing showing property lines and dimensions of same; location of existing structures; wells, ponds, streams, gullies, swamps, etc..; easements, roads, drives, right-of-ways; if present. 3. Proposed (or existing) location of structure(s) to be served by the system; proposed system location. TYPE OF STRUCTURE PROPOSEDSingle Family Res.Single Family Res. # of BR?# of BR?Garbage Disp?Garbage Disp? Basement?Basement?Commercial Commercial Type of BusinessPublic Facility Public Facility Type of Facility# of Design Units# of Design UnitsGallons/Unit/DayGallons/Unit/DayTotal Daily WasteflowTotal Daily WasteflowFor commercial and public facilities, refer to Table 1, Section 8. System sizing standard (pages 49-52) of 902 KAR 10:085 for design daily waste flow sizing based on type of facility.X I (or my designated agent), wish to be present during the site-evaluation.wish to be present during the site-evaluation.I do not wish to be present during the site-evaluation, and waive this right. I, do not wish to be present during the site-evaluation, and waive this right. TO BE COMPLETED BY LOCAL HEALTH DEPARTMENT*Evaluation Fee $ 200.00 Date for Evaluation: 2020 Paid By: Cash Check # Time: AM/PM CAPTCHA
