Application for Permit INSTRUCTIONS

Transcription

1 Application for Permit INSTRUCTIONS Please read the information below. Fill out information on the next page and include your signature and date. Submit required documents and completed form with appropriate fee. Please provide the following information when submitting the application 1. A completed application form. Boxes in gray are required. a. Fees: Check all appropriate fees required. If installing a sewage treatment system (STS), mark Sewage Permit. If an alteration is being made to the existing STS such as but not limited to a change in the system components, expansion of the treatment or dispersal system. Operational Permit must be check in both cases. The operational permit will be valid for 5 years from the approved installation or alteration. If abandoning a system that is not being replaced, please mark the abandonment of system box. Include all fees at time of submitting the application. b. Property Address: Before a permit can be issued the property must have an address. Contact the 911 Coordinator to obtain an address ( ) c. Mailing Address: Provide a current mailing address. Include an address if available. Our preferred form of communication is . If that is not provided, the listed mailing address will be used. d. Contractor: Contractor information must be completed. No permit will be issued without this section being complete. All contractors must be registered with the Putnam County Health Department e. Builder: If building a new dwelling, provide the contractor information. f. No additional design plans or site drawings are required if they have not changed. If there were any changes to the design or the layout of the property include those with the application. Approval of the permit will not be given until the design is approved. g. Sign and date the application. 2. Layout Plan of system. Your contractor will need to provide a layout plan of the system being installed or any alterations being made. This must be submitted prior to the permit being issued. 3. Memorandum of Understanding (MOU). A signed MOU must be on file prior to issuing the permit. 4. Statement of Special Conditions. A signed Statement must be on file prior to issuing the permit. The proposed action must meet the zoning for all townships in Putnam County. Please check with the zoning inspector in the township for proper approval for the project. The STS permit is not valid until a sanitarian has signed and approved the permit application, and has assigned a permit and audit number. The permit is valid for one year from the issue date. Prior to final approval of the STS, a sanitarian will conduct a final inspection of the system to ensure proper installation. The final inspection must be requested by the homeowner and/or contractor and will need to be schedule with a Sanitarian at the Putnam County Health Department prior to covering the system. This inspection is also prior to the system being put into operation. If the STS is installed prior to obtaining an approved permit from the Putnam County Health Department, legal action may be taken and a late fee will be assessed to the permit fee. Once all paperwork is completed and submitted it will be reviewed by a Sanitarian at the Putnam County Health Department. When it is approved, an installation permit will be issued and provided to the applicant and contractor. Revised 1/2015

2 Application for Sewage Treatment System Permit Sewage Permit $424 Alteration of Existing Treatment System $210 Operational Permit (REQUIRED) $75 Abandonment of System $50 TOTAL FEES $ Received Receipt # Requestor/Owner Site Address Contractor (Must be registered with PCHD) Estimated Cost of System: City, State, Zip Street Address Township/Section # City, State, Zip # of Bedrooms Contractor Phone Number Requestor/Owner Mailing Address Contractor Street Address Home Builder (If applicable) City, State, Zip Builder Contact Person Phone Number Builder Contact Person Phone Address construction to begin / date construction completed Is the system requesting to be permitted the same as presented for site evaluation Yes No If different, a new design must be submitted and approved before installation permit will be issued. I hereby agree to comply with all requirements of the OAC Further, I agree to construct the system in accordance to all plans and specifications provided and approved by the Putnam County Health Department. Failure to do so will result in the permit being voided and possible legal action being taken. Owner/Applicant Signature Permit Reviewed By: Variance requested? Yes No Description: Approved Yes No Site Eval # Design Approval System to be Installed Revised 1/2017

3 Installer Layout Plan Property Owner _ Property Address Installer ***All information below must be included with this form or the Sewage Treatment System permit will not be issued*** 1. A drawing showing the layout of the proposed sewage treatment system must accompany this form. The drawing must include the following information and must be labeled and provide distances from the sewage treatment system. a. Any structures on the property f. Other hardscapes b. Well and/or water source g. Property lines c. Driveway h. Geothermal d. Utility service lines i. Rivers/streams/any other bodies of water e. Roadways j. Any other necessary distances 2. Please provide the following information. If not applicable please note with N/A. Manufacturer Model a. Tank b. Pump Station c. Distribution box d. Effluent Filter e. Pump f. Control Panel g. h. i. By signing this form you are agreeing to install the Sewage Treatment System designed for the site on this property to the specifications of the design that is on file and approved by the Putnam County Health Department. If there are any questions about the design, they must be addressed with the designer and any changes must be submitted to the Putnam County Health Department for approval prior to installation. If installation is not done to the specifications in the design, approval of the system may not be given by the Putnam County Health Department and the Sewage Treatment System may not be used. Installer Signature Revised 1/2017

4 PUTNAM COUNTY HEALTH DEPARTMENT HOUSEHOLD SEWAGE TREATMENT SYSTEM MEMORANDUM OF UNDERSTANDING By signing below, each homeowner understands the following terms and conditions: I,, understand that any Household Sewage Treatment System (HSTS), including the Advanced Enviro-Septic (AES) manufactured by Presby Environmental has no known life-span and there are many factors that determine the long-term performance of each HSTS. The Ohio Department of Health has approved the AES system manufactured by Presby Environmental to be installed in Ohio. The Putnam County Health Department (PCHD) has no data on success or failure rates of the recently approved AES systems due to the relatively low number of systems installed and in operation to date. The PCHD Environmental Health Division inspects, to the best of their knowledge, every type of HSTS as they are being installed to ensure compliance with current regulations in an attempt to maximize the practical life-span of the HSTS. The best way to promote long term operation of any HSTS is to perform preventative maintenance including, but not limited to the following: regular pumping of the septic tank; routine cleaning of the effluent filter; resting 25% of the trenches for 6 months, if required and switching between beds for resting, if required. Each registered contractor installing a product manufactured by Presby Environmental, such as the AES system, must be registered with Presby Environmental as being certified to install their products, in addition to being a Registered Installer with the PCHD. It is the view of the PCHD Environmental Health Division that the homeowner is responsible to notify any future owner of the preventative maintenance that has been performed on the HSTS and any future maintenance and/or preventative maintenance that should be completed or scheduled for the HSTS. Property Address/Location City & Zip Code Print Name Signature Protecting and Promoting the Public s Health

5 Household Sewage Treatment System Statement of Special Conditions In accordance with Putnam County Health Department (PCHD) Sewage Treatment System Regulations, I hereby acknowledge the household sewage treatment system (HSTS) being installed at the property named below is not a conventional HSTS and has special conditions that must be met. I understand the PCHD shall not issue a HSTS installation permit unless the applicant acknowledges they have been provided with the following information: 1. The infiltrative surface (bottom) of the leaching trench of the soil absorption component (leach field) shall be installed at or above the seasonal high water table (SHWT), also referred to as a perched water table, and above any associated restrictive soil layer. A conventional system requires two feet of separation; the HSTS on this property will have less than two feet of separation from the SHWT. 2. Frequent monitoring of the HSTS is required and the PCHD may collect samples or observe the system at any time. 3. It the responsibility of the property owner to disclose all information contained in this document to future owners of this property. 4. The HSTS must be designed and installed per site-specific requirements provided by the PCHD in the Site Evaluation Results. 5. For new construction, the building sewer line may need to be installed at a raised elevation if a gravity-flow system is preferred and to avoid the use of a lift station and pump. This often necessitates raising the foundation higher than normal building standards and requires a coordinated planning effort between the HSTS contractor and the foundation contractor to determine the proper elevation for a gravity-flow system. 6. Future modifications to the HSTS will be required if the system is found to be failing as designed as determined by the PCHD. By signing below, I agree the six (6) conditions listed above are met. In addition, I concur that I have been informed the soils on my property are not conducive to a fully-functioning conventional HSTS and I am requesting a permit for a system that may have limited time period within which it is functional due to the presence of a relatively Protecting and Promoting the Public s Health

6 shallow SHWT and soil characteristics present on this property. I also understand that my system is a soil-absorption based system and these systems perform more effectively when used as intended and at their designed capacity. I acknowledge receipt and understanding of the handout Do s and Don ts of On-Site Sewage System Operation and I am aware that water conservation and limiting the amount of solids put into the HSTS are keys to extending the longevity of the HSTS. Property Address/Location City & Zip Code Print Name Signature Protecting and Promoting the Public s Health