Adams County Health Department

ADAMS COUNTY HEALTH DEPARTMENT

108 W. MAIN, RITZVILLE, WASHINGTON 99169 (509) 659-3316 ►◄ 425 E MAIN, Ste. 700, OTHELLO, WASHINGTON 99344 (509)488-2031

ON-SITE SEWAGE SYSTEM PERMIT APPLICATION

*(THIS IS NOT A PERMIT)*

Applicant’s Name: ______Phone # ______Cell # ______

Fax # ______

Mailing Address: ______Email: ______

Site Location: ______Lot Size: ______

Parcel Number: ______Township: ______Range: ______Section: _____

Plat Name: ______Block # ______Lot # ______

APPLICATION FOR: WATER SUPPLY

[ ] New Residential Septic Tank/Drainfield ($450.00) [ ] Private Well (serving only one house)

# of bedrooms ______[ ] Community System

Name ______

[ ] Residential Repair/Alteration ($350.00) [ ] Farm Exempt Well

# of bedrooms ______[ ] Two-Connection Well ------

[ ] New Non-Residential Septic Tank/Drainfield ($450.00) INSTALLER # of Employees ______[ ] Property Owner

[ ] ACHD Licensed Installer

[ ] Other ($55.00 per hour) Company ______

Do you plan to add extra bedrooms or a shop with a living area in the future? [ ] Yes [ ] No

______

INSTRUCTIONS:

·  This is an application for a permit and must be submitted and a permit received prior to the construction of an on-site sewage system. It is illegal to install a sewage disposal system without first obtaining a permit from Adams County Health Department.

·  Fees will be charged in accordance with the current fee schedule, and must be submitted with the application.

Fees paid are non-refundable and non-transferable.

·  Use the attached page for a plot plan. The plot plan must be legible and have accurate scale drawing.

·  The permit applied for is subject to applicable zoning laws and it is the permittees responsibility to comply with said laws prior to installation.

·  Each applicant shall have the right of appeal to any decision made by the Health Officer.

*I certify, by signature, that I am the fee simple owner or contract purchaser of this property. I further certify that I grant permission to allow the Health Officer and/or his representative(s) to enter said property at their discretion for the purposes of application evaluation, water system inspection, or any subsequent inspection.*

Signature: ______Date: ______

Date Received:______Receipt # ______Amount Received:______ACHD Official:______

Plot Plan for On-Site Sewage Permit Application

Instructions

Draw to scale using a straight edge, include units (example 1 inch = 10 feet).

Include: building size and location, driveway and patios, well location and water lines, property lines and dimensions, adjacent roads with names, include a North arrow, surface waters and drainages, drain field layout with replacement area identified, indicate general slope of land, neighbors wells (irrigation and domestic), all real/planned underground utilities and all easements/restriction pertinent to the lot. This does not need to done to engineer quality, but it does need to be complete, legible – and TO SCALE.

Updated 05.2015