14 CAR pt. 21, Appendix F
Requirements for Submission of an Onsite Wastewater System Permit Application
1. All items will be submitted in triplicate to the local health unit with the permit fee or through electronic submission.
2. Completed Onsite Wastewater System Permit Application Form.
3. Vicinity Map.
4. The drawing to be to scale using either 1 inch = 20 feet or 1 inch = 30 feet. The drawing shall indicate the house, Onsite wastewater system components, and other features affecting the location of primary and secondary absorption areas.
5. The direction of North shall be indicated.
6. Property lines shall be defined and their dimensions shown. Dimensions that cannot be indicated by scale shall be designated by a shown distance between 2 indicated points. The distance to 2 adjacent property lines shall be shown to tie the system to one location on the lot.
7. Onsite wastewater system setbacks and their distances must shall be shown. Structures and their dimensions and all features, which affect the locations of system setbacks including the location of utility/service lines, shall be shown.
8. The driveway and parking area dimensions must shall be shown.
9. The location and elevation of the water well shall be shown along with their distance from all parts of the onsite wastewater system and secondary absorption area. For public water systems, show the distances from the onsite wastewater system's components and secondary absorption area location to the water mains and the water service lines.
10. The location, elevation and distances of all wells and/or onsite wastewater systems on adjoining properties that are within 100 feet of the proposed septic system and secondary absorption area shall be shown.
11. Locate and properly size the primary and secondary absorption area and include contour lines or arrows indicating the direction and degree of the lot's slope shall be shown.
12. A benchmark shall be designated and elevation shots or rod readings shall be shown for all parts of the wastewater system. Ground elevation and flow-line elevations shall be provided for all system components. This includes the stub-out and the beginning, middle and end of each absorption trench. Each absorption trench shall be designed on contour, not to exceed 2 inches difference in elevation from beginning to end.
13. The tank sizes and locations shall be indicated.
14. Unusual soils or topographies that affect the site shall be shown and identified. Examples include: excavations, ponds, streams, rock outcrops, drainages, government take lines, etc.
15. The location of percolation test holes on the property shall be shown. All percolation test
holes used in determining the absorption area size shall be within the primary absorption area location.
16. The location of all soil pits on the property shall be shown.
17. The flow line elevation of the building sewer stub-out shall be indicated on the plans. The flow line elevations of all tank inlets and outlets shall be provided. The flow line elevation of the distribution box or other device inlet and outlet shall be provided. The elevation of each trench bottom shall be provided.
18. The location of the cleanout(s) shall be shown.
19. Pipe specifications for all parts of the system shall be provided.
20. The absorption trench depth shall be indicated.
21. The absorption trench media/product shall be indicated.
22. Soil information including hydraulic conductivity, redoximorphic features and depth to bedrock found in the primary and secondary absorption areas from the soil pit shall be provided.
23. Pumped effluent systems
a. All pertinent data required for conventional system shall be provided. b. Indicate the calculated dose volume. c. Provide the construction details on the dose tank. d. Indicate the length and diameter of the pumped effluent line. e. Indicate the length and diameter of the pipe from dose chamber to the distribution system. f. Indicate the elevation difference between the inlet to the distribution system and pump's shut-off elevation. g. Provide the brand, model number and pump curve of effluent pump specified. Include the calculations used to determine the dose volume per minute and friction head. h. Provide details of the pump control assembly not limited to floats, alarm or control panels, electrical wiring
24. Indicate the diversion device to be used and its location.
25. Systems included in the Onsite Monitoring Program shall be submitted with a valid contract with a Certified Monitoring Provider.
The Designated Representative submits a completed Individual Onsite Wastewater System Permit Application (EHP-19) along with detailed plans, product specifications, and required fees. This application package is submitted to the appropriate local health unit.
The following information shall be provided on the Individual Onsite Wastewater System Permit Application (EHP-19). The requirements for each item are explained below. Print or type the information required.
The type of application being requested is indicated by checking the appropriate box in the upper left corner of the EHP-19. The permit choices are:
√ NEW INSTALLATION – Any individual onsite wastewater system that has not been permitted.
√ ALTERATION/REPAIR
Alteration - Any change or extension to an existing, permitted system.
Repair - The restoration of a malfunctioning existing, permitted system to proper function.
The fee amount is calculated from the chart in the upper right corner of the EHP-19 and marked with a check in the appropriate box.
In the first block of Part I (Treatment Type), check the Treatment Type proposed. If the Treatment Type is not listed on the EHP-19, mark Other (OTH).
In the second block of Part I (Disposal Method), check the Disposal Method proposed. If the Disposal Method is not listed on the EHP-19, mark Other (OTH).
The information required for items 1-24 is explained by the item's number as found on the EHP-19, for information not applicable use N/A:
1. The name of the owner/applicant. If the structure is a "spec house," the builder's name can be used, but the homeowner's name should be added prior to the final inspection.
2. The telephone number of the person listed in item 1. This is required in the event the Environmental Health Specialist needs to discuss an issue with the property owner.
3. The mailing address of the applicant.
4. The county in which the proposed system is located.
5. The address of the proposed system. If a 911 address is not available, simple and accurate directions are required.
6. The name of the subdivision where the system is located. If the proposed system site is not located in a subdivision, mark this space with N/A.
7. The date the subdivision in item 6 was approved by the Department of Health.
8. The date the subdivision in item 6 was recorded at the county courthouse. If the subdivision was not recorded, mark this space with “not recorded.” If the subdivision was filed and recorded prior to July 1, 1977, the permit may be reviewed under either the current rules or the applicable rules. This must be addressed on the permit application. If not applicable, mark this space with N/A.
9. The subdivision lot number of the proposed system. If not applicable, mark this space with N/A.
10. The dimensions, in feet, of the property. These dimensions shall correspond to the dimensions shown on the plat drawing. The dimensions shall be entered. Do not use the notation “refer to the plat drawing”.
11. The total area of the lot in acres.
12. For residential systems, list the total number of bedrooms. For non-residential systems, list the number of people using the system on a daily basis.
13. Indicate the estimated daily flow in gallons per day (GPD). For residential systems, the gallons per day per bedroom rates used to design the system must shall be stated. Non-residential systems are based on Appendix B, Quantities of Wastewater Flow for Various Types of Establishments, which can be found in the Rules Pertaining to Individual Onsite Wastewater Systems.
14. Provide a brief legal description for the site of the proposed system. The legal description should be taken down to a minimum of two and one-half (2 ½) acres.
15. Indicate whether the site will be supplied water by either a public water system or a private well. If the water will be from a public system, list the name of the supplier.
16. Indicate the GPS coordinates (longitude and latitude) of the center of both the primary and secondary disposal sites or the point of discharge, whichever is appropriate.
17. Indicate the loading rates (Should be the same as found on Soil Criteria 22(h) Primary Area and 23(h) Secondary Area). If applicable, indicate the percolation rates for the Primary Area and the Secondary Area. The percolation rate for the secondary area shall not be used in finding the average percolation rate.
18. System Specifications: Record the size/dimensions of the proposed system’s components.
a. Record the total liquid capacity, in gallons, of the septic tank(s) to be used. b. Record the liquid capacity of the dose tank, in gallons, to be used. If no dose tank is required, mark N/A. c. Record the size, in square feet, of the absorption area required. d. Record the number of absorption trenches (field lines) to be used. e. Record the length of the absorption trenches (field lines). If the absorption trenches are of different lengths, record all lengths used. Absorption trenches of different lengths are only allowed for serial distribution and pressure distribution designs. If more space is needed, use the comments section on page two. f. Record the depth, in inches, at which the proposed absorption trenches trenches are to be installed. g. Indicate the minimum absorption trench spacing, center to center, to be used. Remarks. This space is provided for any additional information the Designated Representative deems pertinent. h. Indicate the trench media options. i. Indicate the trench width appropriate to the trench media options.
19. The signature of the applicant or use the EHP-19, OPT-A form and indicate in the signature space. "See EHP-19, OPT-A".
20. The information in this box must be either typed or printed, with the exception of the Designated Representative's signature.
21. The Environmental Health Specialist responsible for the system review completes this item.
22. Soil Criteria for the Primary Disposal Area. If percolation tests are used to design the system, items 22 (e-h) and 23 (e-h), are marked N/A.
a. Record the depth, in inches, to bedrock. For the definition of bedrock, refer to the Department of Health's Bedrock policy. b. Record the depth, in inches, to the observed brief seasonal water table. List N/A, if a seasonal water table is not present. c. Record the depth, in inches, to the observed moderate seasonal water table. List N/A, if a seasonal water table is not present. d. Record the depth, in inches, to the observed long seasonal water table. List N/A, if a seasonal water table is not present. e. Record the depth, in inches, to the adjusted moderate seasonal water table. f. Record the depth, in inches, to the adjusted long seasonal water table. g. Record the class and depth of the hydraulic conductivity used to design the system. h. Record the loading rate, in gallons per square foot per day, used in the system design.
24. If present, indicate the seasonal water table. Should be the same as items 22 (b, c, d) and 23 (b, c, d). List the Redoximorphic Features and/or Clay Content Restrictions (Refer to 14 CAR § 21-701 et seq., in the Rules Pertaining to Onsite Wastewater Systems, for wording). List N/A, if a seasonal water table is not present.
Comments: Use as needed for additional system information.
Part 2 Installation Inspection: Completed and signed by the Environmental Health Specialist (EHS) responsible for the system review, or may be made by the Designated Representative (DR) at the approval of the Authorized Agent. If no final inspection has been conducted, the installer may complete the inspection information, but must shall sign and date in the System Installation Verification Section.
Part 3 Permit for Operation: Completed and signed by the Environmental Health Specialist (EHS) responsible for the system review.
Comments: Use as needed for additional system information.
Site Revalidation: Use as needed for site revalidation completed and signed by the EHS or DR. Attach additional sheets, if necessary.
1. A Vicinity Map.
2. The drawing to be to scale using either 1 inch = 20 feet or 1 inch = 30 feet. The drawing shall indicate the house, all septic system components and all other features affecting the location of primary and secondary disposal locations.
3. The direction of North shall be indicated.
4. Property lines shall be defined and their dimensions shown. Dimensions which cannot be indicated by scale shall be designated by a shown distance between two indicated points. The distance to two adjacent property lines shall be shown to tie the system to one location on the lot.
5. Structures and their dimensions shall be shown. All features shall be shown which affect the locations of system setbacks, including the location of utility/service lines.
6. The driveway and parking area dimensions shall be shown.
7. The location and elevation of the water well and water supply line shall be shown, along with their distance from all parts of proposed septic system location and secondary disposal location. For public water systems, show the distances from the septic system's components and secondary disposal location to the water mains and the water service lines.
8. The location, elevation and distances of all wells and/or septic systems on adjoining properties that are within 100 feet of the proposed septic system and secondary area shall be shown.
9. All septic system setbacks and their distances shall be shown.
10. In the primary and secondary disposal site locations, contour lines or arrows indicating the direction and degree of the lot's slope shall be shown.
11. A benchmark shall be designated and elevation shots or rod readings shall be shown for all parts of the sewage system. Ground elevation and flow-line elevations shall be provided for all system components.
12. The septic tank size and location shall be indicated.
13. Unusual soils or topographies that affect the site shall be shown and identified. Examples include: excavations, ponds, streams, rock outcrops, drainages, government take lines, etc.
14. The location of all percolation test holes on the property shall be shown.
15. The location of all soil pits on the property shall be shown.
16. The flow line elevation of the building sewer stub-out shall be indicated on the plans. The flow line elevations of septic tank inlets and outlets shall be provided. The flow line elevation of the distribution box or other device shall be provided. The elevation of each trench bottom shall be provided.
17. The location of the cleanout(s) shall be shown.
18. Pipe specifications and lengths for all parts of the system shall be provided.
19. The primary absorption area shall be properly sized.
20. The absorption trench depth shall be indicated.
21. The secondary area shall be indicated and properly sized.
22. The soil determination, percolation test or soil pit in the secondary area shall be indicated.
23. Soil information in regards to redoximorphic features and bedrock found in the primary disposal site soil pit shall be provided.
24. Pumped effluent systems
a. All pertinent data required for a conventional system must shall be provided. Indicate the calculated dose volume.
b. Provide the dose tank size (item 18b on EHP-19) and the construction details,. If a pump vault is used, indicate the proper, increased septic tank size in item 18a and on the plat drawing.
c. Provide details of the control panel, riser, and pump control assembly. Indicate whether the dose interval is controlled by timer or by demand. Specify what brand panel and control assembly are to be used.
d. Calculate the draw down in the dose tank and the show calculations used. Examples are: 'On-off' points, elevations inside tank alarms, etc.
e. Provide the brand, model number and pump curve of effluent pump specified. Include the calculations used to determine the dose volume per minute and friction head.
f. Indicate the length and diameter of the pumped effluent line.
g. Indicate the length and diameter of the pipe from dose chamber to the distribution system.
h. Indicate the elevation difference between the inlet to the distribution system and pump's shut-off elevation.
i. Provide details of the distribution system.
25. Indicate any diversion or distribution device to be used and its location.
26. Systems included in the Onsite Monitoring Program shall be submitted with a valid contract with a Certified Maintenance Provider.
1. All major system components shall be staked-out with all stakes identified. Examples, include but not limited to, the stub-out, tank, distribution device, beginning, middle and end of each lateral line.
2. The beginning, middle and end of all laterals shall be flagged in both the primary and secondary site. Exception: The secondary site shall have only the field corners flagged on grade provided the lot is 1.5 acres or larger in size.
3. The house/structure location shall be flagged.
4. All percolation test holes shall be flagged.
5. All soil pits shall be flagged.
6. The proposed system design shall be appropriate for the site: flat ground, pumped effluent, serial distribution, dual absorption field, distribution box, dosed, etc.
7. Note observations or other findings.
8. All wells on the property and adjacent properties within 100' of the proposed system shall be identified and flagged.