Onsite Sewage Disposal Systems Application For Site Evaluation This field is hidden when viewing the formApplication No.Application No.This field is hidden when viewing the formDate ReceivedDate ReceivedThis field is hidden when viewing the formCountyCountyTO BE COMPLETED BY APPLICANTApplicant's NameApplicant's NameOwner's Name (if different)Owner's Name (if different)Present AddressPhoneEmail Location of PropertyAcreage / Lot #This field is hidden when viewing the formATTACH 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
