APPLICATION FOR SOIL AND LOT EVALUATION

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Carol Wood
5 years ago
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1 14012 Route 31 West Albion, New York APPLICATION FOR SOIL AND LOT EVALUATION For Installation of Individual Sewage Disposal System Please complete and forward to the above address: Attention Environmental Health Date Forms Completed: APPLICANT Name: Present Home Address: City Zip Code Home Phone Work Phone Please indicate which number you can be reached at between (9am and 5pm). Owner s Name, Mailing Address, and Phone No. (If different from above). PROPOSED SITE LOCATION: Town of Road Name Lot Dimensions feet x feet Acres Brief Travel Directions: PROPOSED RESIDENCE No. of Bedrooms No. of Occupants Is land tiled? Yes No Dishwasher: Yes No Garbage Disposal Unit: Yes No Automatic Clothes Washer: Yes No Indoor Hot Tub: Yes No Water Source: Private Well Public Water (If private well, please have expected location marked by the well driller). CONTRACTORS Septic System Contractor s Name Business Address Telephone Building Contractor s Name Business Address Telephone Please complete the attached FEE SCHEDULE and return with Application. Signature of Property Owner DATE

2 14012 Route 31 West Albion, New York PERCOLATION TEST INSTRUCTIONS An integral part of a properly designed sewage disposal system is the evaluation of soil in which the system will lay. Percolation tests of the soil determine the acceptability of the site and the design of the subsurface sewage disposal system. PROCEDURE: Hand dig three (3) holes in the area designated for the leach field. These holes should have horizontal dimensions of 12 inches and vertical sides to the depth of 30 inches. A six (6) foot pit should be provided in the center of the three (3) small percolation holes. This hole should be six (6) foot deep and wide enough for observations related to the ground water table and soil profiles. When the three (3) small holes and six (6) foot pit are completed, call the Health Department at or between 9am and 5pm, Monday through Friday. At this time an appointment will be made with a representative of the Environmental Health Division to proceed with the percolation tests. Fill the three (3) small holes with 5-7 gallons of water 24 hours before the percolation test is to be conducted. DO NOT put water in the six (6) foot hole. Have 5-7 gallons of water at the site of each small hole the day of the percolation test. As soon as the soil percolation tests are performed and evaluated, the results will be mailed to you. This procedure generally takes about seven (7) days. The fee for the issuance of a Sewage Disposal System Permit is $

4 ENVIRONMENTAL FEE SCHEDULE You or your representative have recently requested this Department to provide the service selected below. In order that this service may be provided, please submit this form with a check for the appropriate amount to this Department at your earliest convenience. NAME: PAID ADDRESS: Check # Cash Amount: PHONE: Received By: FOOD PROTECTION: Low Risk... $ Medium Risk $ High Risk.. $ Seasonal Operation.... $ Bakery... $ Catering Operations $ Catering Commissary. $ Mobile Unit (per vehicle) $ Mobile Unit Commissary $ Temporary (14 days or less). $ Multiple Temporary (180 Consecutive Days). $ Frozen Dessert $ TEMPORARY RESIDENCES, CAMPS AND RECREATION: Children's camp inspection & permit (for profit). $ Motel/hotel inspection & permit: 1 25 rooms $ rooms. $ rooms $ Campsite inspection & permit: 1-10 sites $ sites $ sites. $ Plan review: temporary residence (per site) / campsite (per lot)... $ Bathing beach: inspection, plan review, sampling, analysis & permit.... $ Swimming pool: inspection, plan review & permit... $ Beach / Pool: engineering plan review. $ Migrant labor Camp inspection and permit: 5-10 occupants.. $ occupants.. $

5 Mobile home park plan review per lot.. $ Mobile home park inspection and permit: 5-50 units/sites.. $ units/sites.. $ units/sites $ PRIVATE SEWAGE / WATER: Soil Percolation Test (2 tests, permit, final inspection). $ Additional Perc Test..... $ Replace/Repair Existing septic system $ Evaluation of Septic System (additional $150 if new system required). $ Evaluation of Water System (includes bacteriological sampling & analysis)... $ Water Sample (per sample).. $ Departmental Plan Review $ Engineering Plan Review $ Realty subdivision plan review, per lot. $ PUBLIC WATER SUPPLY: Community water supply inspection... $ Purchase System Inspection. $ Community water district - Engineering plan review.... $ Public water supply bacteriological sampling and analysis.. $ Non-community water supply inspection, bacteriological sampling & analysis. $ Non-community water supply plan review.. $ Ag. & Markets or USDA Survey $ Bottled and bulk water inspection. $ GENERAL: Smoking waiver: Initial Approval.. $ Renewal $ Mass Gathering... $ A late fee of 50% of the permit fee is charged to all permitted facilities that do not remit their fee prior to the expiration of their existing permit. Temporary/Multiple Temporary food service must have their application submitted at least one week prior to an event or a late fee of 50% will be charged. There will be a service charge for all returned checks. Cash settlements will be made at the County Treasurer s office

LORAIN COUNTY PUBLIC HEALTH ENVIRONMENTAL HEALTH FEES

LORAIN COUNTY PUBLIC HEALTH ENVIRONMENTAL HEALTH FEES FOOD SERVICE OPERATION & RETAIL FOOD ESTABLISHMENT RATES COMMERCIAL RATES (C) UNDER 25,000 SQ. FT. LOCAL FEE STATE FEE RISK LEVEL 1 $ 226.00 $ 28.00