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Charles Harris, MD-Health Officer On-Site Sewage System Permit Application Application for: ☐ New construction I ☐ Alteration or Replacement of Existing I ☐ Tank Only I ☐ Drain Only If Repair, Reason for Repair: ☐ System Age I ☐ Damaged System I ☐ Illegal Discharge I ☐ Surface Failure I ☐ Other: Previous permit _ Original system date Owners Name: Site Address: _ Address: _ City: Subdivision: _ City, State, Zip: Lot Township: Phone: _ Email: Parcel Is the property located within the 100-year floodplain? ☐ Yes ☐ No Water Source: ☐ Public Water Supply I ☐ Proposed Well I ☐ Existing Well Septic System & Secondary Disposal Information Septic Tank: ☐ 1 or ☐ 2 compartment I Manufacturer/Model: Size: gal Basement Grinder Pump: ☐ Yes I ☐ No *If yes, then a 2-compartment septic tank is required* Effluent Filter: Manufacturer: Model: _ Dose Tank: Manufacturer/Model: Size: gal ☐ Combo Septic/Dose: Manufacturer: Septic: _ gal Dose: gal Secondary Treatment: ☐ Single Pass Media Filter ☐ Recirculating Media Filter ☐ Aerobic Treatment Unit Make/Model: Distribution: ☐ Gravity Flow I ☐ Flood Dose I ☐ Pressure Distribution ☐ Absorption ft²: Trench Depth: Aggregate Spec: _ ☐ Chamber ft²: Trench Depth: Make/Model: ☐ Sand Line Make/Model: Lineal Ft: _ Depth: Basal Area: _ x ☐ Sand Mound Basal Area: _ x Aggregate Bed Depth: ☐ Drip Irrigation Lineal Ft: _ Make/Model: Drainage ☐ Perimeter ☐ Interceptor ☐ Segment ☐ N/A I Size: ☐ 4” ☐ 6” IDepth: _ Agg. Type: _ Text. Wrapped: ☐ Yes ☐ No I, the undersigned, do now affirm under penalties of perjury that the foregoing information and/or representations are true and further do now certify that septic construction for this parcel will be installed to meet State and local requirements of the Health Department of Hamilton County, Indiana. Date: _ Signed: January 2024 18030 Foundation Drive, Suite A Noblesville, IN 46060 Phone: (317) 776-8500 Fax: (317) 776-8506 Installer: Designer: _ Email: Phone: _ Contact: Phone: _ ☐ 1 or 2 family dwelling # of Bedrooms + jetted tubs ≥ 125 gal I ☐ Commercial DDF: _ IDOH Project Permit Number: Completed System Approved: _ Date: _ SIGN