Application for Septic Permit (Conventional Systems)

 Step 1 of 1

This application is for the septic installer to complete when placing a trench system.

* Denotes a required field
Date:*
 
 
Owner Phone: 
-- ext
 

Site Address

 
 
 
 
ZIP 
-
Second portion of ZIP Code is optional.

Installer Information

*
Installer's Phone:*
-- ext
*
By checking the box below, I hereby certify that I am the installer named above and that I am authorized to request a permit for the above property, in accordance with Indiana Code 410 IAC 6-8-3.
I agree with the above Statement.*
 
Water Supply Source: 
Trench System Type: 

Sewer Pipe

 
 
 

Septic Tank

 
 
 

Dose Tank

 
 
 

Effluent Pump

 
 
 
 
 
 
 
*All pump electrical connections make be completed inside a NEMA 4x junction box.*

Force Main

 
 
 
 
Pumping Uphill? 

Distribution Box

 
 
 

Absorption Field

Type: 
*If Chamber or Other, please indicate Manufacturer and Model below:
 
 
 
 
 
 
 
 

Drainage

 
 
 
Drainage Type: 
Socked Tile: 
Drain Outlets to: