Onsite Sewage System Application Application Type New Construction Repair/Replacement Component Applicant Information Owner's Name date_range access_time Owner's Email date_range access_time Mailing Address date_range access_time Mailing Address 2 date_range access_time City date_range access_time State Please select an option Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip date_range access_time Home Phone 111-111-1111 date_range access_time Work Phone 111-111-1111 date_range access_time Mobile Phone 111-111-1111 date_range access_time Installer Information (if known) Installer's Name date_range access_time Mailing Address date_range access_time Mailing Address 2 date_range access_time City date_range access_time State Please select an option Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip date_range access_time Work Phone 111-111-1111 date_range access_time Mobile Phone 111-111-1111 date_range access_time Property Description Address or Location of Property date_range access_time Parcel ID date_range access_time Civil Township date_range access_time Subdivision date_range access_time Lot date_range access_time Parcel or Lot Size date_range access_time Structure Description # of Bedrooms date_range access_time Number of Occupants date_range access_time Jetted Tub > 125 gal? Yes No Jetted Tub Capacity date_range access_time If Yes, Jetted Tub # date_range access_time Garbage Disposal? Yes No Full Body/Waterfall Shower? Yes No If Yes, Full Body/Waterfall Shower GPM date_range access_time Seasonal Use? Yes No Year Structure Built date_range access_time Water Softener? Yes No Rental Property? Yes No Water Supply Source Private Well Community Water Source Other This application is not complete until an on-site soil evaluation, which meets the requirements of Rule 410 IAC6-8-3-56, has been submitted. I am the: Property Owner Property Owner's Agent I, the undersigned, do now affirm under penalties of Perjury that the forgoing information and/or representations are true, and further do now certify that the On-site Sewage System for this facility will meet the laws and codes of the State of Indiana and the Sullivan County Health Department. * navigate_nextSubmit Your Session Is About To Expire Click continue to extend your session. Your Session Has Expired Close your browser or click OK to begin a new session.
