Form DFS-345 "Application for Site Evaluation and Permit to Operate a Disposal Site" - Kentucky

What Is Form DFS-345?

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

Form Details:

  • Released on September 1, 1996;
  • The latest edition provided by the Kentucky Department of Public 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 fillable version of Form DFS-345 by clicking the link below or browse more documents and templates provided by the Kentucky Department of Public Health.

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Download Form DFS-345 "Application for Site Evaluation and Permit to Operate a Disposal Site" - Kentucky

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DFS - 345 (9/96)
CABINET FOR HEALTH SERVICES
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DEPARTMENT FOR PUBLIC HEALTH
APPLICATION FOR SITE EVALUATION AND PERMIT TO OPERATE A DISPOSAL SITE
APPLICATION NO.
COUNTY
HEALTH DEPT. / DISTRICT
DATE RECEIVED
OWNER'S NAME
ADDRESS
CITY
ZIP CODE TELEPHONE NO.
STATE
SITE OPERATOR'S NAME
CITY
ZIP CODE TELEPHONE NO.
ADDRESS
STATE
LOCATION OF SITE:
COUNTY
CITY
DIRECTION TO SITE:
ATTACH THESE DOCUMENTS WITH THE APPLICATION
SCALED AND DIMENSIONED SITE PLAN
MONITORING PROGRAM (IF APPLICABLE)
1.
8.
NUMBER OF ACRES WITH SITE BOUNDARIES
LAND USAGE
2.
9.
STRUCTURES AND OTHER FACILITIES
NITROGEN REQUIREMENT
3.
10.
PROPOSED DISPOSAL AREAS
APPLICATION RATE
4.
11.
APPROVAL LETTER FROM LOCAL PLANNING AND ZONING
SET BACK DISTANCES ON/OFF SITE
12.
5.
ENDANGERED SPECIES STATEMENT
ACCESS ROADS
13.
6.
PROPOSED OPERATIONS PLAN
OTHER REQUIRED BY CABINET
7.
14.
I,
do affirm or attest that the information given to the
Health Department
is true and correct to the best of my knowledge.
Owner Signature
Date
(TO COMPLETED BY THE HEALTH DEPARTMENT)
SITE EVALUATION
DEPTH TO
DISPOSAL
SITE
LANDSCAPE
SOIL
DEPTH TO
SOIL DEPTH
AVAILABLE
RESTRICTIVE
METHOD
TOPOGRAPHY
POSITION
TEXTURE
WATER TABLE
SPACE
HORIZON
SURFACE
APPLICATION
SHALLOW
INCORPORATION
DEEP
INCORPORATION
Page 1 of 2
DFS - 345 (9/96)
CABINET FOR HEALTH SERVICES
Reset Form
Print Form
DEPARTMENT FOR PUBLIC HEALTH
APPLICATION FOR SITE EVALUATION AND PERMIT TO OPERATE A DISPOSAL SITE
APPLICATION NO.
COUNTY
HEALTH DEPT. / DISTRICT
DATE RECEIVED
OWNER'S NAME
ADDRESS
CITY
ZIP CODE TELEPHONE NO.
STATE
SITE OPERATOR'S NAME
CITY
ZIP CODE TELEPHONE NO.
ADDRESS
STATE
LOCATION OF SITE:
COUNTY
CITY
DIRECTION TO SITE:
ATTACH THESE DOCUMENTS WITH THE APPLICATION
SCALED AND DIMENSIONED SITE PLAN
MONITORING PROGRAM (IF APPLICABLE)
1.
8.
NUMBER OF ACRES WITH SITE BOUNDARIES
LAND USAGE
2.
9.
STRUCTURES AND OTHER FACILITIES
NITROGEN REQUIREMENT
3.
10.
PROPOSED DISPOSAL AREAS
APPLICATION RATE
4.
11.
APPROVAL LETTER FROM LOCAL PLANNING AND ZONING
SET BACK DISTANCES ON/OFF SITE
12.
5.
ENDANGERED SPECIES STATEMENT
ACCESS ROADS
13.
6.
PROPOSED OPERATIONS PLAN
OTHER REQUIRED BY CABINET
7.
14.
I,
do affirm or attest that the information given to the
Health Department
is true and correct to the best of my knowledge.
Owner Signature
Date
(TO COMPLETED BY THE HEALTH DEPARTMENT)
SITE EVALUATION
DEPTH TO
DISPOSAL
SITE
LANDSCAPE
SOIL
DEPTH TO
SOIL DEPTH
AVAILABLE
RESTRICTIVE
METHOD
TOPOGRAPHY
POSITION
TEXTURE
WATER TABLE
SPACE
HORIZON
SURFACE
APPLICATION
SHALLOW
INCORPORATION
DEEP
INCORPORATION
Page 1 of 2
ARE SET BACK DISTANCES MET ?
YES
NO
If no, list missing setbacks:
PAID: (check one)
YES
NO
EVALUATION FEE
DATE EVALUATION TO BE CONDUCTED
EVALUATION DATE
CONDUCTED BY
ARRIVAL TIME
DEPARTURE TIME
MILEAGE
PERMIT TO OPERATE
HEARING REQUESTED
SITE APPROVED
YES
NO
YES
NO
YES
NO
COUNTY/DISTRICT HEALTH DEPARTMENT
ENVIRONMENTALIST
ID #
OWNER/OPERATOR (MUST BE PRESENT)
OWNER/OPERATOR'S SIGNATURE
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