CABINET FOR HUMAN RESOURCESDEPARTMENT FOR HEALTH SERVICES ONSITE SEWAGE DISPOSAL SYSTEMS APPLICATION FOR SITE EVALUATIONAplication No.Date Received MM slash DD slash YYYY CountyTO BE COMPLETED BY APPLICANTOwner's Name (If Different)Applicant's NameEmail* Present Address Street Address City State / Province / Region ZIP / Postal Code Phone No.Location of PropertySubdivisionLot No.Block No.Dimensions of LotSquare FootageAcreageATTACH TO THIS APPLICATION THE FOLLOWING:1. Location map to reach the site. 2. Site drawing showing property lines and dimensions of same; location of existing structures; wells, ponds, streams, gullies, swamps, etc; easements, roads, drives, right-of-ways; if present. 3. Proposed (or existing) location of structure(s) to be served by the system; proposed system location_File AttachmentsUpload necessary files here Drop files here or Select filesMax. file size: 1 GB.TYPE OF STRUCTURE PROPOSEDSingle Family Residence YesNo. of BedroomsGarbage Disposal Yes NoBasement Yes NoCommercial YesType of BusinessPublic Facility YesType of FacilityNo. of Design UnitsGallons/Unit/DayTotal Daily WasteflowFor commercial and public facilities refer to Table 1, Section 8- System Sizing Standards (Pages 49-52 )of 902 KAR 10:085 for design daily waste flow sizing based on type of facility.I (or my designated agent), wish to be present during the site evaluation. I, do not wish to be present during the site evaluation, and waive this right. Agent NameNameTO BE COMPLETED BY LOCAL HEALTH DEPARTMENTEvaluation Fee: $Paid By: Cash Check Money OrderDate for EvaluationTimeAM or PM AM PMNOTE: Backhoe pits may be required for evaluation.County or District Health DepartmentCertified Inspector* Additional fee and application required for construction permit.
