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DFS-319 (REV. 3/97))
CABINET FOR HEALTH SERVICES
DEPARTMENT FOR PUBLIC HEALTH
ONSITE SEWAGE DISPOSAL SYSTEMS APPLICATION FOR SITE EVALUATION
Application No.
Date
-
Month
-
Day
Year
Date
County
TO BE COMPLETED BY APPLICANT
Owner's Name (If Different)
Applicant's Name
Present Address
City
State
Zip Code
Phone No.
Format: (000) 000-0000.
Location of Property
Subdivision
Lot No.
Block No.
Dimensions of Lot
Square Footage
Acreage
ATTACH 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.
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TYPE OF STRUCTURE PROPOSED
Single Family Residence
No. of Bedrooms
Garbage Disposal
Garbage Disposal Yes/No
Yes
No
Basement
Basement Yes/No
Yes
No
Commercial
Type of Business
Public Facility
Type of Facility
No. of Design Units
Gallons/Unit/Day
Total Daily Waste Flow
For 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.
TO BE COMPLETED BY LOCAL HEALTH DEPARTMENT
Evaluation Fee: $
Cash
Check
Money Order
Date for Evaluation:
-
Month
-
Day
Year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
NOTE: Backhoe pits may be required for evaluation.
County or District Health Department
Certified Inspector
* Additional fee and application required for construction permit.
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