Form EHP-19 "Individual Onsite Wastewater System Permit Application" - Arkansas

What Is Form EHP-19?

This is a legal form that was released by the Arkansas Department of Health - a government authority operating within Arkansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2013;
  • The latest edition provided by the Arkansas Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form EHP-19 by clicking the link below or browse more documents and templates provided by the Arkansas Department of Health.

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Download Form EHP-19 "Individual Onsite Wastewater System Permit Application" - Arkansas

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Receipt Number
Arkansas Department of Health
Environmental Health Protection
Individual Onsite Wastewater System Permit Application
Fee Schedule for Structures
Structures 1500 sq ft or less
$ 30.00
Permit Type
New Installation
Structures more than 1500 sq ft and up to 2000 sq ft
$ 45.00
Alteration / Repair
Structures more than 2000 sq ft and up to 3000 sq ft
$ 90.00
Structures more than 3000 sq ft and up to 4000 sq ft
$120.00
DR Environmental ID #
Structures more than 4000 sq ft
$150.00
Alteration and Repair
$ 30.00
Part 1 Application
Treatment Type (check one)
Disposal Method (check one)
STD = Standard Septic Tank
ATU = Aerobic Treatment Plant
STD = Standard Absorption Field
LPD = Low Pressure Distribution
ISF = Intermittent Sand Filter
RSF = Re-circulating Sand Filter
SUR = Surface Discharge
HLD = Holding Tank
PMF = Proprietary Media Filter
RGF = Re-circulating Gravel Filter
CPF = Capping Fill
SRL = Serial Distribution
OTH = Other (Describe)
HLD = Holding Tank
OTH = Other
DRP = Drip Irrigation
1. Owner’s/Applicant’s Name
2. Phone Number
3. Mailing Address
4. County
5. Address of Proposed System (If a 911 address is not available, attach detailed directions or map)
6. Subdivision Name
7. Approval Date
8. Date Recorded
9. Lot Number
10. Lot Dimensions
11. Total Area (Acres)
12. # Bedrooms # People
13. Daily Flow (GPD)
14. Brief Legal Description of Property (Attach a separate sheet of paper, if necessary)
15. Water Supply (Specify supplier, if Public Water)
16. GPS Coordinates
17. Loading Rates
(gpd/ft²)
18. System Specifications
Primary Area
a. Size of Septic Tank
gal
f. Trench Depth
inches
Secondary Area
b. Size of Dose Tank
gal
g. Trench Spacing
feet
Percolation Test
(min/in)
c. Absorption Area
ft²
h. Trench Media (List Below)
i.Trench Width
Primary Area Avg
d. Number of Field Lines
in
Secondary Area
e. Length of Field Lines
ft
in
TO THE OWNER
The permit for construction may be deemed invalid by the local Environmental Health Specialist before the start of construction, if the site and/or
soil conditions have changed after approval of this permit, or if the information within this permit is inaccurate or has been found to be
misrepresented. Approval for operation does not constitute a guarantee that the system will function properly. The approval states that the
system was designed and installed according to the Arkansas Department of Health, Rules and Regulations Pertaining to Onsite Wastewater
Systems, unless there are exceptions or deviations noted in the comments. A Permit for Construction is valid for one (1) year from the date of
approval. The authorized agent must revalidate a permit more than one (1) year old prior to the start of any construction.
19. Utilization Verification
I hereby attest that item 12, the number of bedrooms (number of persons for commercial) and square footage of the structure that will
utilize the designed individual onsite wastewater system in this permit application, is accurate. I have reviewed the permit application and
understand the layout, installation, maintenance, operation and expense(s) that may be associated with this system.
Owner/Applicant Signature___________________________________________________________ Date ____________________________
20. I certify that I have conducted the above tests and that the above listed information is in accordance with the latest requirements of the
Arkansas Department of Health Rules and Regulations Pertaining to Onsite Wastewater Systems.
Soil Certified
Yes
No
Designated Representative Signature
Title
Print Name
Date
Phone Number
21. Approval of Health Authority
The information and specifications in the application has been reviewed and found to meet the requirements of the Arkansas Department of
Health Rules and Regulations Pertaining To Onsite Wastewater Systems. A PERMIT FOR CONSTRUCTION is hereby issued.
____________________________________________________________ _________________________ ___________________________
Environmental Specialist Signature
EHS Number
Date
EHP-19 (R 8/13) Page 1
of 2
Receipt Number
Arkansas Department of Health
Environmental Health Protection
Individual Onsite Wastewater System Permit Application
Fee Schedule for Structures
Structures 1500 sq ft or less
$ 30.00
Permit Type
New Installation
Structures more than 1500 sq ft and up to 2000 sq ft
$ 45.00
Alteration / Repair
Structures more than 2000 sq ft and up to 3000 sq ft
$ 90.00
Structures more than 3000 sq ft and up to 4000 sq ft
$120.00
DR Environmental ID #
Structures more than 4000 sq ft
$150.00
Alteration and Repair
$ 30.00
Part 1 Application
Treatment Type (check one)
Disposal Method (check one)
STD = Standard Septic Tank
ATU = Aerobic Treatment Plant
STD = Standard Absorption Field
LPD = Low Pressure Distribution
ISF = Intermittent Sand Filter
RSF = Re-circulating Sand Filter
SUR = Surface Discharge
HLD = Holding Tank
PMF = Proprietary Media Filter
RGF = Re-circulating Gravel Filter
CPF = Capping Fill
SRL = Serial Distribution
OTH = Other (Describe)
HLD = Holding Tank
OTH = Other
DRP = Drip Irrigation
1. Owner’s/Applicant’s Name
2. Phone Number
3. Mailing Address
4. County
5. Address of Proposed System (If a 911 address is not available, attach detailed directions or map)
6. Subdivision Name
7. Approval Date
8. Date Recorded
9. Lot Number
10. Lot Dimensions
11. Total Area (Acres)
12. # Bedrooms # People
13. Daily Flow (GPD)
14. Brief Legal Description of Property (Attach a separate sheet of paper, if necessary)
15. Water Supply (Specify supplier, if Public Water)
16. GPS Coordinates
17. Loading Rates
(gpd/ft²)
18. System Specifications
Primary Area
a. Size of Septic Tank
gal
f. Trench Depth
inches
Secondary Area
b. Size of Dose Tank
gal
g. Trench Spacing
feet
Percolation Test
(min/in)
c. Absorption Area
ft²
h. Trench Media (List Below)
i.Trench Width
Primary Area Avg
d. Number of Field Lines
in
Secondary Area
e. Length of Field Lines
ft
in
TO THE OWNER
The permit for construction may be deemed invalid by the local Environmental Health Specialist before the start of construction, if the site and/or
soil conditions have changed after approval of this permit, or if the information within this permit is inaccurate or has been found to be
misrepresented. Approval for operation does not constitute a guarantee that the system will function properly. The approval states that the
system was designed and installed according to the Arkansas Department of Health, Rules and Regulations Pertaining to Onsite Wastewater
Systems, unless there are exceptions or deviations noted in the comments. A Permit for Construction is valid for one (1) year from the date of
approval. The authorized agent must revalidate a permit more than one (1) year old prior to the start of any construction.
19. Utilization Verification
I hereby attest that item 12, the number of bedrooms (number of persons for commercial) and square footage of the structure that will
utilize the designed individual onsite wastewater system in this permit application, is accurate. I have reviewed the permit application and
understand the layout, installation, maintenance, operation and expense(s) that may be associated with this system.
Owner/Applicant Signature___________________________________________________________ Date ____________________________
20. I certify that I have conducted the above tests and that the above listed information is in accordance with the latest requirements of the
Arkansas Department of Health Rules and Regulations Pertaining to Onsite Wastewater Systems.
Soil Certified
Yes
No
Designated Representative Signature
Title
Print Name
Date
Phone Number
21. Approval of Health Authority
The information and specifications in the application has been reviewed and found to meet the requirements of the Arkansas Department of
Health Rules and Regulations Pertaining To Onsite Wastewater Systems. A PERMIT FOR CONSTRUCTION is hereby issued.
____________________________________________________________ _________________________ ___________________________
Environmental Specialist Signature
EHS Number
Date
EHP-19 (R 8/13) Page 1
of 2
Individual Onsite Wastewater System Permit Application
Receipt Number
Continue Part 1
22. Soil Criteria (Primary Area)
Indicate the depth to items a-f, if observed in the soil (designate in inches)
2
a. Bedrock
b. BSWT
c. MSWT
d. LSWT
e. Adj. MSWT
f. Adj. LSWT
g. H.C./Depth
h. Loading Rate (gpd/ft
)
23. Soil Criteria (Secondary Area)
Indicate the depth to items a-f, if observed in the soil (designate inches)
2
a. Bedrock
b. BSWT
c. MSWT
d. LSWT
e. Adj. MSWT
f. Adj. LSWT
g. H.C./Depth
h. Loading Rate (gpd/ft
)
24. Seasonal Water Table (SWT) Classes Detail
Primary Area
List Redoximorphic Features and/or Clay Content Restrictions
Brief
in
Moderate
in
Long
in
Secondary Area
List Redoximorphic Features and/or Clay Content Restrictions
Brief
in
Moderate
in
Long
in
Comments
Part 2
Installation Inspection
Septic tank manufacturer
Pump information
Septic tank material
Trench media and width
Dose tank manufacturer
Depth of interceptor drain
Dose tank material
Depth of settled fill
Name of Installer
License Number
Installation Inspected by
□ Environmental Health Specialist
□ Designated Representative
(check one or installer signs System Installation Verification below)
_____________________________________________________________ ____________________________ ______________________
Signature
EHS / License Number
Date
System Installation Verification
I have installed this system as designed and in compliance with all Rules and Regulations Pertaining to Onsite Wastewater Systems.
_____________________________________________________________ _____________________________ _____________________
Installer Signature
License Number
Date
Part 3
Permit for Operation
The information contained in Part 1 and 2 of this form has been reviewed and found to meet the requirements of the Arkansas Department of
Health. THE PERMIT FOR OPERATION of this system is hereby issued.
Environmental Health Specialist ___________________________________ _____________________________ ____________________
Signature
EHS Number
Date
Comments
□ Environmental Health Specialist
□ Designated Representative
Site Revalidation conducted by
(check one)
_____________________________________________________________ _____________________________ _____________________
Signature
EHS / License Number
Date
EHP-19 (R 8/13) Page 2 of 2
Page of 2