CABINET FOR HUMAN RESOURCESDEPARTMENT FOR HEALTH SERVICES ONSITE SEWAGE DISPOSAL SYSTEMS APPLICATION FOR SITE EVALUATION Aplication No.Date Received MM slash DD slash YYYY County TO BE COMPLETED BY APPLICANTOwner's Name (If Different) Applicant's Name Email* Present Address Street Address City State / Province / Region ZIP / Postal Code Phone No.Location of Property Subdivision Lot No. Block No. Dimensions of Lot Square Footage Acreage ATTACH TO THIS APPLICATION THE FOLLOWING: 1. Location map to reach the site. 2. Site drawing showing property lines and dimensions of same; location of existing structures; wells, ponds, streams, gullies, swamps, etc; easements, roads, drives, right-of-ways; if present. 3. Proposed (or existing) location of structure(s) to be served by the system; proposed system location_File AttachmentsUpload necessary files here Drop files here or Select files Max. file size: 5 GB. TYPE OF STRUCTURE PROPOSEDSingle Family Residence Yes No. of Bedrooms Garbage Disposal Yes No Basement Yes No Commercial Yes Type of Business Public Facility Yes Type of Facility No. of Design Units Gallons/Unit/Day Total Daily Wasteflow For commercial and public facilities refer to Table 1, Section 8- System Sizing Standards (Pages 49-52 )of 902 KAR 10:085 for design daily waste flow sizing based on type of facility. I (or my designated agent), wish to be present during the site evaluation. I, do not wish to be present during the site evaluation, and waive this right. Agent Name Name TO BE COMPLETED BY LOCAL HEALTH DEPARTMENTEvaluation Fee: $ Paid By: Cash Check Money Order Date for Evaluation Time AM or PM AM PM NOTE: Backhoe pits may be required for evaluation.County or District Health Department Certified Inspector * Additional fee and application required for construction permit.