Download Randolph County Health Department ON

Randolph County Health Department
ON-SITE WASTEWATER TREATMENT SYSTEM REPAIR APPLICATION
APPLICATION NUMBER:____________________________________
INSTRUCTIONS
Under Ordinance RCRV-12202011 the Randolph County Health Department (RCHD) is required to regulate the
design, construction and repair of all on-site wastewater treatment systems (OSWTS). The packet contains
forms and instructions to assist you in repairing your OSWTS in a manner that will comply with Missouri State
Statutes.
If you are adding on to an existing soil absorption system you will need to contact a licensed soil evaluator for
a soil morphology in the area that you intent to utilize. A list of soil evaluators can be obtained at Randolph
County Health Department or online at www.dhss.mo.gov/Onsite/Professionals. The results of this report will
determine whether or not the area intended for the additional absorption line is adequate. A soil morphology
is not necessary if the septic tank or pipes are being replaced.
Complete the attached application. Your contractor or Randolph County Health Department representative
can assist you with this. Return this application, with the soil report if required, the fee form and fee, and all
drawings to the Randolph County Health Department. Upon receipt and review of the completed application
a site visit will be scheduled with your installer. If the results of the site visit and plan review are satisfactory, a
repair permit will be issued, and your installer may begin the repair.
In the event that the plan is not accepted by the regulatory authority, it is your right to request a hearing by
the Review Board. Requests must be submitted in writing to the Regulatory Authority within 10 days of receipt
of the report from the Regulatory Authority stating why the plan was not accepted.
Upon completion of the repair and prior to covering, the installer shall notify the Randolph County Health
Department. If the Randolph County Health Department is unable to be at the site by 3:00 pm, the installer
may cover the system and sign a waiver of proper construction provided by the Randolph County Health
Department. A final inspection/approval report will be issued to the homeowner. In the event that the repair
does not adhere to the plan submitted or does not comply with the State Standard, a letter of non-compliance
will be issued which will list any and all defects to be corrected. A follow-up inspection will be made upon
resolution of the defects and the final inspection/approval shall be issued.
Randolph County Health Department
Application for Repair of On-Site Wastewater Treatment System
1. Property Owner Name _____________________________________________________________
Last
First
MI
2. Site Address:______________________________________________________________________
______________________________________________________________________
City
Zip Code
Latitude
Longitude
3. Legal Description:__________________________________________________________________
(¼
¼
Section
Range
Township)
4. System serves: Residence/Business/Part Time Usage
Number of Bedrooms:___________
Whirlpool Tub: Yes No
Laundry Facility (commercial) Yes No
Daily Water Usage:____________
Garbage Disposal: Yes No
Dishwasher: Yes No
5. What is the current wastewater system?
Septic Tank__________________ with Absorption Field___________________________________
Tank Size
Number Lines and Length
Septic Tank _________________ with Lagoon___________________________________________
Tank Size
Lagoon Size
Lagoon ONLY:___________________________________
Lagoon Size
Other:___________________________________________________________________________
Description
6. When was the current system installed? Year:_______________
7. What type of repair is needed?_______________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Installer Name:___________________________________________________ ID Number:________________
Telephone Number:___________________________________
Address:__________________________________________________________________________________
All information contained in and with this application packet is true and accurate to the best of my knowledge.
_______________________________________________________________
Signature of Owner/Agent
______________________
Date
SITE LAYOUT
Show property lines and dimensions. Diagram the proposed system and stake it on the property for the Site
Evaluation. Show distances to house, well, waterlines, property lines, geologic features (sinkholes, rock
outcroppings, lakes, ponds, streams, etc) Show test. Show known easements for utilities, roads, private
driveways, etc.
Randolph County Health Department
ON-SITE REPAIR APPLCATION FEE FORM
DATE:____________________
APPLICATION NUMBER:__________________________________
Name of Property Owner:____________________________________________________________________
Address of Construction Site:__________________________________________________________________
_________________________________________________________________________________________
Mailing Address:___________________________________________________________________________
Telephone Number:_______________________________________________________
NON-REFUNDABLE APPLICATION FEE:
Make checks or money orders payable to:
Randolph County Health Department
Environmental Health Services
P.O. Box 488
Moberly, MO 65270
$75.00