Receipt
Date
AMT. / $
Ini.

FORT WAYNE-ALLEN COUNTY DEPARTMENT OF HEALTH

APPLICATION FOR CONSTRUCTION PERMIT

FOR ONSITE SEWAGE SYSTEM

(RESIDENTIAL)

OFFICE USE ONLY: / (INSTALLLER) :

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

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 / PRIVY / (CHECK ONE)
NUMBER OF BEDROOMS / SUMP PUMP / BASEMENT / (YES OR NO)
LOT SIZE / (DIMENSIONS) / (ACRES)
CLOSEST DISTANCE FROM SEPTIC OR DOSING TANK TO: (FEET)
1.) WELL / 2.) DWELLING / 3.) PROPERTY LINE
NAME OF TANK MANUFACTURER
LIQUID CAPACITY: / 1.) SEPTIC / 2.) DOSING / (GALLONS)
WHERE DOES BASEMENT FLOOR DRAIN DISCHARGE?
WHERE DOES SINK AND LAUNDRY WASTE DRAINAGE DISCHARGE?
WHERE DOES EFFLUENT FROM SEPTIC TANK DISCHARGE?
WHERE DO DOWNSPOUTS DISCHARGE?
WHERE DO FOOTING DRAINS DISCHARGE?
CLOSEST DISTANCE FROM SECONDARY DISPOSAL FIELD TO: (FEET)
1.) WELL / 2.) DWELLING / 3.) PROPERTY LINE
(1) ABSORPTION FIELD: TOTAL LENGTH OF LATERALS / (FEET)
WIDTH OF ABSORPTION TRENCHES / (INCHES)
TOTAL BASAL AREA / (SQUARE FEET)
OTHER

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

SUBMIT LOT LAYOUT OF RESIDENCE. Show location of septic tank, dosing tank absorption field (or other secondary system), all pipes connecting the various parts of the system, well(s) drains, drainage ditches, driveways, roads, property lines, out-buildings and rough floor plan of house. All of the above mentioned items should be sufficiently labeled and dimensioned. Layout must be drawn to scale and scale shown.

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.)

When installation has been inspected and approved an Operational Permit will be issued from the Allen County Onsite Wastewater Management District.

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

Application for Construction Permit Residential 8-6Pollution Control
2/28/2012 MRW/JKS 10 Fort Wayne-Allen County Dept. of Health