FEE: $40.00 - NONREFUNDABLE Receipt # _______________
DARKE COUNTY GENERAL HEALTH DISTRICT
300 Garst Avenue
Greenville, Ohio 45331
Phone: (937) 548-4196 Fax: (937) 548-9654
EVALUATION OF EXISTING HOME SEWAGE SYSTEMS
PLEASE SEND EVALUATION RESULTS TO:
Name __________________________________________ Phone # _______________________
Address ______________________________________________________________________
City, State, Zip _________________________________________________________________
LOCATION OF REQUESTED EVALUATION
Name_______________________________________ Phone # __________________________
Address ______________________________________________________________________
City _______________________________________Township _________________________
Subdivision _____________________________ Lot # _____T____R____S____
Directions: ____________________________________________________________________
Is the home occupied or vacant? _____________ If vacant, how long? _____________________
When was the home built? _________________ Builder of home: _____________________
Number of bedrooms: _____ System has (circle): aeration tank septic tank
The Health Department files records of septic systems by the homeowners last name when the system was installed (with some exceptions).
Name of the homeowners from 1950 to present: Year purchased:
____________________________________ ____________________
____________________________________ ____________________
____________________________________ ____________________
____________________________________ ____________________
IS THIS INSPECTION FOR A HOME SALE? Yes No
IS THIS INSPECTION FOR A HOME REFINANCE? Yes No
IS THIS INSPECTION FOR A LAND SPLIT? Yes No
IF YES, COMPLETE APPLICATION FOR WATER TESTING.
Continued on Other Side
The lids of the septic tank and distribution boxes (if applicable) must be uncovered prior to the time of inspection. If there are no risers on the inlet and outlet lids of the septic tank, they will be required. If the system has a dry well, uncover the lid to the dry well. If the system has a subsurface sand filter, the outlet tile must be uncovered in order to sample the quality of the effluent. An inspection port will be required on the outlet tile of the sand filter if one does not currently exist. A scavenger registered with the Darke County Health Department must pump the septic tank while the inspector is present. A list of scavengers is available upon request.
The inspectors opinion of the system may be rendered without knowledge of some of the individual parts of the home sewage system and applies only to the date and time the opinion is made. Therefore, the opinion does not guarantee the future performance of the home sewage system.
The owner/applicant agrees to the requirements of the special service inspection and understands that upgrades may be required if deemed appropriate by the Health Department. If for any reason you must cancel or reschedule the appointment, you must call in at least 24 hours prior to the originally scheduled appointment.
Applicant ___________________________________________________ Date____________
Homeowner or representative____________________________________ Date____________
FOR OFFICE USE ONLY______________________________________________________________
Septic System is: Approved _____Disapproved _____Inspector______________________Date_________
DATE PUMPED_____________ PUMPER____________________ # GALLONS__________
PERMIT ISSUED YES NO DATE OF ISSUANCE:______________________
.
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): ______Ft.
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
DATE OF APPOINTMENT: ________________________ TIME: __________________
LAST REVISED: JANUARY 11, 2008