Fee: $100.00 - NON-REFUNDABLE Receipt #__________
Last Revised:
Darke
County General Health District
Phone: (937) 548-4196 Fax: (937) 548-9654
For a 1-3 family residence
You must make an
appointment with the Sewage Inspector, phone: 937-548-4196 extension 208 to
submit this application to the Darke County Health Department. Applications will not be accepted without an
appointment.
Plan Submitter: Builder Homeowner Installer (circle one)
Applicant’s Name: _________________________________Phone #: _____________________
Affiliation to Owner: ____________________________________________________________
Applicant’s Mailing Address: _____________________________________________________
Owner’s Name: ___________________________________ Phone #: _____________________
Current Mailing Address: ________________________________________________________
Site Address: __________________________________________________________________
Directions: ____________________________________________________________________
Township of site: ____________________________ Total Acreage: _________________
Subdivision Name: ___________________________
Township
#
Has the lot already been split, platted, and recorded? Y N If yes, date recorded: __________
Interceptor, gradient drain, or other surface water drains outlet to (circle only one):
(A) Stream located on property
(B) County tile/county ditch located on property
(C) Existing tile to county tile, county ditch, or stream with recorded easement
(D) New tile to be installed to county tile, county ditch, or stream with recorded easement
If a stream, county
tile, or county ditch is not located on your property an easement must be
obtained from all properties to such drainage.
The easement area must include the area the existing or proposed tile is
located. This easement must be recorded at the recorder’s office in the
courthouse prior to permits being granted. Information on county tiles and
ditches may be obtained at the county engineer’s office. The Health Department
will want to inspect any tile prior to granting approval for its use.
Name of county ditch/ tile draining to: ______________________________________________________________________________
Drainage easements to be obtained/already obtained from the following property owners:
______________________________________________________________________________
______________________________________________________________________________
Prior to the evaluation of your lot, the following must
be done:
_____ Submit the site
evaluation application and fee for building lot approval (this form)
_____ Submit the attached Site and Soil Evaluation Form (last page of this application, a soil evaluator must complete; a list of potential soil evaluators is available at the health department as well as the instructions on how they should complete this form. All Soil Evaluators and Designers must meet the competency requirements of the rules. The Health Department may not recommend and does not guarantee the competency of those individuals on the list. If you know of someone who wishes to be included on the list, let us know).
_____ Submit a site plan or site drawing with proposed location of house, septic, well, etc.
It must be drawn to scale and also must include
the following:
o The dimensions of the lot or the proposed lot.
o Any other structures to be located on the lot.
o Any site disturbances, existing or proposed driveways or other hardscapes
o Location of soil boring and or excavation locations for attached soil evaluation
-designate the areas for which the soil profiles are representative on the plan
o Location of primary and reserve septic systems
o Identify any areas that would impact or prohibit the siting of the septic systems
o Location of well and other wells located within 50ft of lot
o North orientation arrow.
o Vegetation present, approximate slopes, and drainage features
o Drainage tiles
o Any easements located on the property
_____ Submit a 1/4 section map with property owners
indicated (1”=200 ft.). The section map must include an aerial map with plat
overlay and soil profile. (Obtain from
GPS Map Office located in basement of courthouse)
_____ Submit surveyed
copy of the plat (w/ site review letter from review board, if < 5 acres) (Obtain
from
_____ Submit a copy of the blueprints or the floor plan of the home to be built at this time. Estimated gallons per day of waste to be treated: _________.
A 3 bedroom home typically generates
360 gallons per day
A 4 bedroom home typically generates
480 gallons per day
A 5 bedroom home typically generates
600 gallons per day. Please note office, den, study, etc. and any room that can
be used as a bedroom is counted as a bedroom.
______ Submit the design or layout plan for the septic system.
Company designing system: _______________________Contact Person: __________________ Address of designer: _____________________________Phone number: ___________________
Allow thirty days for
the Health Department to review a design plan prior to issuing permits.
A list of potential
designers is available at the health department. Attached are design plan
requirements, Section 3701-29-9.1 of the
_____ Location of home must be staked (corners)
_____ Property lines must be clearly marked.
_____
Closest public sewage system:_______________________________________________
Distance to closest public system: __________________________(feet, yards, or miles)
You may be required to obtain a letter from the public sewer stating that the proposed lot or subdivision will not be allowed to connect or is not accessible to the sewer based upon the distance of the public sewer from the proposed lot or subdivision. Subdivisions with 25 or more lots must be reviewed by the Ohio EPA to determine sewer accessibility and written documentation provided.
Owner/ applicant acknowledgement: To the best of my knowledge, the information include in this application is complete and accurate. I understand and agree that approval for development will be subject to all applicable laws, regulations, and policies. I also understand that if changes occur which would make this application inaccurate, approvals will be void/ revoked until the new changes have been reviewed and new approvals granted. I also certify that the siting of a sewage system on this lot does not violate paragraph (B) of Section 3701-29-8.1 of the Ohio Administrative Code.
_________________________________________ __________________
Owner/ applicant signature Date
If for any reason you need to cancel or reschedule your site appointment, you must call at least 24 hrs prior to the original appointment time. The Darke County Health Department has forty five calendar days upon acceptance of a complete application to determine whether approval may be granted. Health department building lot approvals are valid for one year from the date of approval.
Once the site is
approved, the following must be submitted to obtain health department permits:
______Blue print or floor plan of the home if not already submitted.
______Name of the septic installer:_________________________________________________
______Name of the well driller:___________________________________________________
______Name of the well pump/ pitless adapter installer: ________________________________
______The zoning permit or the un-zoned township approval
letter (Obtain from zoning inspector or
township trustee if in an un-zoned township, see information attached)
______The address (Obtain from county engineer’s office)
______Recorded easements (if applicable) (Obtain from recorder’s office located in
courthouse Many times it is located on the deed
for the property)
______Name of Service Provider: __________________________________________________
All septic systems are required
to have routine maintenance. Lists of service providers and septic haulers are
available at the Health Department. The
design plan and operational permit should specify the type of maintenance
involved with your system.
You must schedule an appointment to obtain your well and septic permits. Most of the time the inspectors are in the field and the secretaries cannot issue you permits. At the time you purchase your well and septic permit, a building authorization will be issued so you may obtain your building permit from the building department. Your plumber will have to obtain your plumbing permit. Permits are good for one year from the date they are issued.
Occupancy will not be
granted by Building Regulations until all health department inspections are
complete.
Once the septic system is approved, an operational permit will be issued. The permit will be valid for the time frame issued on the permit. An inspection will be conducted between 12 to 18 months after the system has been approved. When the operational permit expires, you will be sent a bill for the next operational permit period. At that time, you may be required to submit supporting documentation that you have operated your system in accordance with the maintenance requirements listed in the system’s design.
Please note the health department may, at any reasonable
time, inspect any household sewage treatment system or part thereof, sample the
effluent, or take any other steps which may be necessary to insure proper
compliance with Ohio Administrative Code Chapter 3701-29-01 through
3701-29-18. This will be done at the
discretion of the department and may involve additional work to be done,
paperwork to be filed, and may incur additional fees and/ or costs to be paid.
Larger homes may require larger lots.
All permits may be revoked if the submitted plans are altered without prior approval from the health department.
_____________________________________________________ __________________
Owner/ applicant signature Date
DATE OF APPOINTMENT: ________________________ TIME: __________________
Disapproved___ for the following reason(s): (See below)
____________________________________________________________________
_____________________ ______________
Inspector Date
Type of System:
Aeration_______ _____Lineal Feet___18”___36” Split Field___________________
Tank______gal. w/risers _____Graveless ___18” ___36” Interceptor Drain_____________
Existing___________ _____Upflow Filter Gradient/ Curtain Drain________
________Mound System _____Drip System Inspection Port_______________
Other_______________________
# Bedrooms: _________ Type of installation: New Replacement or Alteration
System Type Code
(Circle): Soil
Credit Used (Circle):
1. Soil Absorption 1. One foot credit used
2. NPDES discharging 2. Two foot credit used
System Description Code (Circle): System Flow (GPD):__________________
1. Septic tank to shallow leach lines Vertical Separation Distance (VSD): ____
2. Pretreatment to shallow leach lines
3. Septic tank to 18”-30” leach lines Estimated Cost:______________________
4. Pretreatment to 18” – 30” leach lines
5. Septic tank to sand mound Easement: Y N
6. Pretreatment to sand mound
7. Septic tank to drip distribution Operational Permit Fee: ______________
8. Pretreatment to drip distribution
9. NPDES System O/M Description (circle): Conventional
10. Other Mechanical
Notes: ______________________________________________________________________
DATE PERMITS ISSUED: ______________________ Plumbing permit needed: YES or NO
Additional
Information
2007 Septic Permit Installation Fee: $300.00 Partial: $150.00
2007 Operational Sewage Permit Fee: $15.00 per year conventional
$35.00 per year mechanical $5.00 per year aeration with service contract
2007 Well Permit Fee: $263.00 Alteration: $113.00 $48.00 for additional waters samples
2007 Plumbing permit fee: $40.00 plus $12.50 per fixture $25.00 plan review fee
Health Department
Contact Information:
Health Commissioner: T.L. Holman, DVM, RS
Environmental Director: Roberta Mangen, RS, MPH
Environmental Secretary: Teresa Plessinger 937-548-4196 ext. 209
Sewage Inspectors: Randy Dues, RS 937-548-4196 ext. 208
Ginger Gehret, RS 937-548-4196 ext. 233
Plumbing Inspector: Lance Begoon, CPI 937-548-4196 ext. 207
Sanitarians: Corrie Holthaus, RS, Janel Hodges, RS
Other Handouts
Available at the Health Department:
o Well isolation distance and other requirements
o Septic installation guidance documents
o Information on care and maintenance of your septic system
o List of Registered Plumbing Contractors
o List of Registered Septic Installers
o List of Registered Septic Pumpers
o List of Registered Service Providers
o List of Soil Evaluators
o List of Designers
CONTACT
INFORMATION
Location:
Basement of
937-547-7375
Planning Commission/ Review Board:
Contact: Curtis Yount
Location:
Basement of
520 S.
Broadway,
Building Regulations:
Contact: Ron Francis
Location:
Basement of
520 S.
Broadway,
Zoning:
Unzoned Townships: Contact any of the listed trustees
Phone: Phone:
Allen: Neal Siefring
338-6113
Paul Mestemaker 338-5837 Daniel Hart 548-1332
Jerry
Bergman 338-5575 Robert Wagner 337-7491
Mississinawa:
Robert Stump 375-4728
Edward Rauh 375-4319 James Zumbrink 336-7932
Roger Fortkamp 968-7408 Bill Barga 336-6573
Patterson: Samuel Polhman 582-2703
Steven G. Puthoff 582-2007 William Hart 968-6047
Kenneth Bohman 582-5944 Wayne Baker 548-5210
Un-zoned Township Letter
For homes to be built or remodeled in Allen, Mississinawa, Patterson,
To be completed by a township trustee in the respective township.
Submit a copy to:
This is to notify you that the Trustees of _______________ Township, Darke County, Ohio, have inspected the proposed building site or sites of: ___________________________ located at, _________________________________________ and do hereby make the following recommendations:
Proposed site does/does not have
drainage problems with the following exceptions: ____________________________________________________________________________________________________________________________________________________________
Proposed site does/does not have driveway distance problems with the following exceptions: ____________________________________________________________________________________________________________________________________________________________
Other related comments: ____________________________________________________________________________________________________________________________________________________________
This form is submitted for information purposes only. The Trustees acknowledge that they have no obligation to regulate the building site, drainage, or driveway sight distances in regards to this property.
________________________________________________
________________________________________________
(Township Trustee or authorized signature)
________________________________________________
________________________________________________
(Address) _______________________________________________
(Phone number)
________________________________________________
(Date)
Send copy to: _________________________________
(Owner or building contractor)