Online Application for Onsite Sewage System

Reason for Application *

Owner Information

Owner's Name *

Phone * XXX-XXX-XXXX

Owner's Mailing Address *

City *

State *

Zip Code * XXXXX

E-mail Address *

Site Information

Site Address *

City *

State *

Zip Code * XXXXX

Directions to Site: *

Nearest crossroads:

Distance to property

Nearest mailbox number:

Distance to property

Landmarks noticeable from road (i.e. buildings, ponds, etc.)

Other Information

Water Supply *

Number of bedrooms *

Number of bathrooms *

Number of people in house *

Number of jetted bathtubs (whirlpool-type 125 Gal & over) *

Est. Sq. Footage of House *

Installer Name *

Address *

City *

State *

Zip Code * XXXXX

Phone # * XXX-XXX-XXXX

Builder Name *

Address *

City *

State *

Zip Code * XXXXX

Phone # * XXX-XXX-XXXX

$75 non-refundable application fee is required before a permit can be issued. This is an application only, not a permit

I have read this application and hereby certify that, to the best of my knowledge, the information on this sheet is correct. In addition, the water supply and sewage facilities for this building will be installed strictly in accordance with all provisions of Indiana State Law 410 IAC 6-8.3, and with the Parke County Sewage Disposal Ordinance. I will allow Parke County Health Department personnel onto the property at any time for inspections of the septic system.

A permit may be revoked by the Parke County Health Department for failure to comply with Indiana State Department of Health Rule 410 IAC 6-8.3 and/or any other applicable regulations. (Revocation of the permit shall be in writing to the property owner and/or their agent; shall state the reasons for revoking the permit; remedial actions necessary; and upon written request afford the applicant the opportunity for a fair hearing.)

Applicant's Signature *

Date * 01/01/2022