Date___________________
Owners Name___________________________________
Permit #_________
Installer___________________________________________________________
Type of System________________ Purpose__________________
Type of Tank_________________
New System; Tank Replacement; Lateral Modification;
Lagoon; Other
C or P
Inspection Check Points
Section A Tanks Final Layout
1. Permit Posted
Y N
2. Clean out between house & septic tank
Y N
3. Tank set back 10' from house
Y N
4. Sch 40 in & out of septic tank
Y N
5. Baffle T's on inlet & outlet
Y N
6. Pump out riser on tank
Y N
7. Manhole riser & inspection ports (19CSR
20-3.060) Y N
Section B Laterals
1. Solid pipe from tank to distribution box
Y N
2. Cleanouts required in 90' distances or 90
degree turns Y N
3. Laterals installed level
Y N
4. Appropriate footage installed
Y N
5. Inspection port on the end of at least one
lateral line
Y N
6. All set backs met
Y N
Section C Lagoons
1.Solid SDR 35 pipe from tank to lagoon
Y N
2. Cleanout in front of lagoon
Y N
3. 3 to 1 slope on berms
Y N
4. 30'x40' sq. ft
Y N
5. Fence
Y N
6. Blocks or splash pad
Y N
7. Inlet pipe to lagoon center
Y N
8. All set backs met
Y N
Section D Alternative
Type of system__________________________
Plan design_____________________________________________
O Installation
in accordance with plan
O System
complies & meets minimum standards
O Only
tank complies
O System
modified but still remains unapproved for property transfer
THE WASTEWATER PERMIT PROGRAM WAS ESTABLISHED IN JULY 1989 TO
PREVENT SEWAGE POLLUTING IN HENRY COUNTY'S LAKES, RIVERS AND DRINKING WATER SUPPLIES.
The signing of this certificate is not to be construed as official approval of this system, nor does it guarantee the
continued satisfactory operation of the system.
LOCAL HEALTH OFFICIAL___________________________________
