ABC County Health Department
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ABC County Health Department
On-Site Sewage System
Application for Residential On-Site Sewage System
Please Check One
Owner
Builder/Contractor
Agent
Applicant name
Email Address
Primary Phone
Address
City
State
ZIP
Property owner
Phone #
Secondary Phone
Fax#
Property Address
Site address
Subdivision
Lot#
Parcel ID number
Township
T:
T:_____North
R:_____West
Sec: ______
Number of bedrooms
Family
Multiple family
Single family
New (Construction)
Replace Existing System
Check One
Failure
Tank Only
Tie-IN to existing system
Upgrade
Whirlpool tub> 125 gallons: Y / N Garbage disposal: Y / N Water softener: Y / N Rental property: Y / N
Water Supply
City Water
Private Well
I hereby certify that the information above is accurate and true to the best of my knowledge. I agree to construct the house according to the number of bedrooms and to accommodate the placement of the septic system.
Signed
Date
(mm-dd-yyyy)
Print Name
To engage and partner in a collaborative and responsive effort with the community and local organizations with respect to the diversity of the community to better serve present and future generations.
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