RALLS COUNTY HEALTH DEPARTMENT

[Office Location: 405 West 1st) St.] MAIL TO: P.O. Box 434, New London, MO 63459

Phone: (573) 985-7121 FAX: (573) 985-1531

APPLICATION FORM

For An On-Site Wastewater System Construction Permit

NOTE: This Is Not A Permit

Date : ______Number From Construction Permit (for office use): ______

This is a: New system ( ) System repair ( ) System or component replacement ( )

Property Owner/Applicant: ______Home Ph: ______

(PLEASE PRINT : First Name – Last Name)

Current Mailing Address: ______Work Ph: ______

City: ______State: ______Zip Code: ______

Construction Address ______City ______Zip______

(Please supply the 911 Emergency Response System address. Call the 911 system coordinator at (573) 221-1191 and request this address if you don’t know what it is.)

[If no 911 site address is available, provide geographical location: ______1/4 of ______1/4, Section ______, Range ______, Township ______]

Installer: ______ I.D. #: ______Expiration date______Phone # : ______

Address: ______City ______State _____Zip______

I. General Information

  1. Lot Width ______Length ______Acres ______
  2. Number of Bedrooms: ______
  3. Number People Served: ______
  4. Basement Wastewater Drain: Yes ______No ______
  5. Garbage Disposal: Yes _____ No _____
  6. Ground Slope: ______% ______(Direction)

II. Water Supply: Public [ ] Private [ ] If Private Water Supply, Show Location And Distance From Well To Septic

Tank, Lateral Field Or Lagoon On The Sketch (Page 2)

III. Septic Tank

1.New: [ ] Existing: [ ]

2.Size: ______(Gallons) No Tank: [ ]

  1. Construction Material: ______

NOTE: Install A Septic Tank Effluent Filter

NOTE: A Six-Inch Inlet End Riser And An Outlet End Manhole Riser To Or Above Grade Are Required

IV. Secondary Treatment

New [ ] existing [ ] Type ______

(for example, 10-inch gravelless pipe, chambers, lpp)

1. Lateral Trench Depth: ______Width: ______(inches)

2. Number of Lines: ______Length Each ______(Ft)

3. If Unequal Length, List Length Of Each:

1______2______3______4______

5______6______7______8______

4. Total Lateral Line Length: ______(ft)

5. Distribution: Box [ ] Pressure manifold [ ]

other dist./ dosing device______

6. Pump [ ] Pump Tank [ ] Pump Filter [ ] Pump Vault [ ]

7. Curtain Drain [ ] Depth: ______inches

8. Surface Water Diversion: terrace [ ] swale [ ]

If Existing Lateral Field: [ ] Type: ______Number Of Lines: _____ Length Each: ______Length Total: ______

V. Lagoon

  1. Size: ______Square Feet Water Surface Area
  2. Length: ______ft Width: ______Ft

3.Diameter (if round) ______ft

4. Overflow Pipe : Distance From Outer End Of Pipe To

Nearest Property Line: ______Ft

5. Distance From Home Served To Lagoon (nearest shoreline of lagoon): ______Ft

6. Dist.from shoreline to nearest property line:______ft

7. Distance To Nearest Stream, Lake, Etc: ______Ft

8. Distance to nearest neighbors home from lagoon_____ft

NOTE: Lagoon Berms Must Be Smoothed, Seeded With Grass , And Fenced Within 90 Days after Construction

VI. Soil Morphology By:______Report Received By Health Dept: Yes [ ] No [ ]

VII. Certification Of Compliance

I Hereby Certify That This System Will Be Constructed In Accordance With This Application And In Compliance With Missouri State Code(s) And The Ralls County Ordinance(s) Governing On-Site Sewage Disposal.

Owner Signature: ______Date: ______

Installer Signature: ______Date: ______

Continue On The Other Side NOTE: Applications and Permits Expire (12) Twelve Months From Approval Date [ver 1/2014]

(Page 2: Ralls County Sewage System Construction Permit Application)

Show the following on layout Sketch:
A.
Location and length of Property (and/or) Lot lines, house perimeter w/dimensions, wells, septic tank, sewer lines, sewer field(s), Lagoon and lagoon outlet, trees and surface water drainage routes within 100 feet. Nearest neighbors (if within 500 feet of property line. Include distance between all installations or structures.
B.
Slope and drainage direction of ground.
C.
Distance from sewer field constructions to property line and dwelling. Distance between and grade of lateral constructions.
D.
Indicate North. / Layout Sketch:
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Application Approved: Yes [ ] No [ ] ______Date: ______

Name and Title

On-Site Visits & Inspections: ______/______/______/______/______/______

Date & Initials Of Inspector

FINAL APPROVAL OF SYSTEM: Approved: Constructed Per Approved Application YES [ ] NO [ ]

Approved "As Built" ------YES [ ] NO [ ]

Inspector: ______Title:______Date: ______

(a sketch and/or other information showing the system as it was installed must be supplied for “as built” approval)

Comments : [Following Are General Comments , Or , If The System Is Not Approved , Reasons For Non-Approval And Actions Required For Approval] ______

Installer Certification Of System For Approval: I, the undersigned, hereby certify that this on-site wastewater treatment system has been constructed and/or installed in accordance with the RCHD ordinance and the STATE standards, as described within the approved application and supporting documentation supplied to the ralls county health department to obtain the constructionpermit, and/or in accordance with approved supplemental documentation for alterations to the specifications in the permit application for the system.

Installer Signature: ______Date: ______

rev: 1/2014Installer Registration Expiration Date:______