Free 50098.pdf - Indiana

APPLICATION FOR CONSTRUCTION PERMIT
State State Form 50098 (R3 / 8-06) INDIANA STATE DEPARTMENT OF HEALTH / SANITARY ENGINEERING Approved by State Board of Accounts, 2006

DATE RECEIVED

____________

RECEIPT NUMBER ____________ PROJECT NUMBER ___________

INSTRUCTIONS:

1. Send check or money order along with plans to: Indiana State Department of Health P O Box 7236 Indianapolis, IN 46207-7236 2. Direct questions to 317/233-7177

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FAX COPIES OF APPLICATIONS WILL NOT BE ACCEPTED

1. OWNER _________________________
Name ___________________________ Address _________________________ ________________________________ Phone No. _______________________

5. The Following Documents are Attached:
(CHECK WHERE APPLICABLE)

A. Location Map B. Plot Plan C. Legal Description of the Property D. Plans and Specifications certified by Architect or Engineer

2. OWNER'S DESIGNATED AGENT
Name ___________________________ Title _____________________________ Address __________________________ _________________________________ Phone No. ________________________

E. Documents Required by 410 IAC 6-10 (1) Report of Soil Survey Conducted by a Soil Scientist ­ Applicable if Soil Report Not Already Submitted (2) Wastewater Characteristics and Flow Calculations F. Fees Required by 410 IAC 6-12-17 (see other side)

3. FACILITY (TYPE OF PROJECT)
_________________________________ Name ____________________________ Address __________________________ _________________________________ City _____________________________ County _____________ Zip __________ 4. ENGINEER/ARCHITECT Name ____________________________ _________________________________ Address __________________________ _________________________________ _________________________________ Phone No. ________________________ License# _________________________

6. SIGNATURE Application is hereby made for a Permit to authorize the activities described herein. I certify that I am familiar with the information contained in this application, and to the best of my knowledge and belief such information is true, complete, and accurate. ___________________________________ Printed Name of Person Signing ___________________________________ Title ___________________________________ Signature of Owner or Designated Agent __________________________________ Date of Application (month, day, year)

INSTRUCTIONS FOR COMPLETION OF CONSTRUCTION PERMIT
1. Owner Name and address of person, company, firm, municipality, authority, etc., which proposes the construction, installation, or modification of any water pollution control facility. Name, title, address, and phone number of person who is designated to act for owner and who is familiar with the project and can furnish additional information as required. State its name, location, and nearest possible address. Name, title, company, address and phone number of engineer or architect registered in the State of Indiana who certified and sealed the construction plans and specifications. A. A USGS topographic map or a county highway map with the exact site indicated. B. Plot plan or plans to scale showing property lines, structures, roads, water wells within 300 feet of the proposed wastewater disposal facility, and topography with 2-foot contours. C. Detailed legal description of the property proposed for the permitted facility. D. Plans and specifications shall be prepared, certified and sealed by an individual qualified under applicable laws of the State of Indiana. E. Report of an on-site survey identifying soils at the site of the proposed absorption field including textures, and structures at each soil horizon and depth to seasonal high water table or bedrock. F. Fees required by 410 IAC 6-12-17 Commercial on-site Community Wastewater Disposal Facility Mobile Home Park or Mobile Home Park Addition $200 $700

2. Authorized Agent

3. Name of Facility or Project 4. Name of Engineer/Architect

5. Check the squares indicating name of documents attached to Application. All documents are required except where inapplicable.

$300

6.

Signature An application submitted by a corporation must be signed by a principal executive officer of at least vice president level or his duly authorized representative, if such a representative is responsible for the overall operation at the facility from which the construction described in the form will originate. In the case of a partnership or a sole proprietorship, the application must be signed by a general partner or the proprietor, respectively.