Fillable Form provided by: Stark County Health Department: Water (Stark County Government)

Fill Online, Printable, Fillable, Blank Form provided by: Stark County Health Department: Water (Stark County Government) Form

Use Fill to complete blank online STARK COUNTY GOVERNMENT (OH) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form provided by: Stark County Health Department: Water (Stark County Government)

On average this form takes 6 minutes to complete

The Form provided by: Stark County Health Department: Water (Stark County Government) form is 2 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 24 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Stark County Government

BROWSE STARK COUNTY GOVERNMENT (OH) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Form provided by: Stark County Health Department
7235 Whipple Ave NW ● North Canton, OH 44720 ● Phone (330) 493-9904 ● Fax (330) 493-9920 ● www.starkhealth.org
Submit completed form to online@starkhealth.org
THE INSPECTION WAS CONDUCTED BY: _________________________________________________________________
TEST REQUESTED:
______TOTAL COLIFORM ______ FLOW RATE ______ NITRATE/NITRITE
PROPERTY ADDRESS: _____________________________________________ PARCEL: ______________________________
CITY: ___________________________ ZIP: __________________ TOWNSHIP: ______________________________________
OWNER: _____________________________________________ OWNER’S PHONE: __________________________________
BUYER: _____________________________________________ BUYER’S PHONE: ___________________________________
PERSON RESPONSIBLE FOR ACCESS & TITLE: _____________________________________________________________
PHONE: ___________________________ CELL: ____________________________ FAX:
_______________________________
EMAIL RESULTS TO: ______________________________________________________________________________________
(or) FAX TO: _____________________________________FAX NUMBER:____________________________________________
(or) MAIL RESULTS TO: __________________________ ADDRESS: _______________________________________________
Water System Evaluation
PROPERTY DIAGRAM TO BE SUBMITTED ON 8.5 x 11 PAPER, ATTACH TO EVALUATION
MUNICIPAL
WATER? ( YES / NO ) WATER SYSTEM RECORDS AVAILABLE? ( YES / NO ) if yes attach
PRIVATE WATER SYSTEM COSTRUCTION DATE: ___________________________
PRIVATE WATER SYSTEM CONSISTS OF: ____ DRILLED WELL ____DRIVEN WELL ____ DUG WELL ____ CISTERN
____ SPRING ____ OTHER, EXPLAIN _________________________________________________________________________
TYPE OF CASING: ____ STEEL ____PLASTIC ____ OTHER (see comments) DIAMETER: _________ LENGTH:_________
CASING LOCATION: ____ OUTSIDE FOUNDATION ____ INSIDE FOUNDATION
CASING IS: ____ EXPOSED ____IN WELL PIT ____ UNABLE TO LOCATE (BURIED) ____ OTHER (see comments)
TYPE OF SEAL: ____SANITARY WELL SEAL ____ PITLESS ADAPTER CAP ____ OTHER, LIST_______________________
ELECTRICAL CONDUIT IS SEATED/SEALED IN CAP: ( YES / NO )
TYPE OF PUMP: ____ SUBMERSIBLE ____ JET (LOCATION:____________________________) ____ OTHER (see comments)
TYPE OF STORAGE: ____ PRESSURE ____ GRAVITY, DESCRIBE ________________________________________________
LOCATION, DISTANCE TO: _____ SEWER LINE _____ FOUNDATION _____ OTHER POTENTIAL CONTAMINATION
____ PRIMARY SEWAGE TREATMENT _____ SECONDARY SEWAGE TREATMENT _____ PROPERTY LINE
IS WELL ACCESSIBLE FOR CHLORINATION: ( YES / NO ) IF NO EXPLAIN: _________________________________
HOME WATER SYSTEM HAS: _____ CHLORINATOR _____ SOFTENER _____ FILTER(S) _____ OTHER (see comments)
IS AN ADDITIONAL WATER SOURCE AVALIABLE: ( YES / NO ) IF YES EXPLAIN: _____________________________
Water System Evaluation
Form provided by: Stark County Health Department
7235 Whipple Ave NW ● North Canton, OH 44720 ● Phone (330) 493-9904 ● Fax (330) 493-9920 ● www.starkhealth.org
P
ROPERTY ADDRESS:_________________________________________________TOWNSHIP:_________________________
B
ASED ON AVAILABLE INFORMATION, THE WATER SYSTEM IS:
_
_____ HOME IS VACANT. THEREFORE, WATER SYSTEM HAS NOT BEEN IN FULL USE AND MAY NOT
SHOW SIGNS OF DEFECTS, IF ANY, UNTIL FURTHER USE.
______ SATISFACTORY
______ SATISFACTORY, HOWEVER, SEE COMMENTS LISTED BELOW.
______ UNSATISFACTORY
COMMENTS CONCERNING THIS WATER SYSTEM: _____________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
THIS EVALUATION ONLY APPLIES TO THE DATE AND TIME THE EVALUATION WAS MADE, AND IS BASED ON A VISUAL INSPECTION ONLY. KNOWLEDGE OF THE
INDIVIDUAL COMPONENTS MAY BE LIMITED. THIS EVALUATION DOES NOT GURANTEE THE FUTURE CONDITION OR PERFORMANCE OF THE WATER SYSTEM.
THE WATER SYSTEM TEST DOES NOT ASSESS THE CHEMICAL QUALITY OF THE WATER, OTHER THAN WHAT IS LISTED ABOVE. PLEASE NOTE THAT MANY
FACTORS DETERMINE FLOW RATE, SUCH AS: PIPE SIZE, PUMP SIZE, SAMPLE LOCATION, STORAGE TANK PRESSURE, AND WELL PRODUCTION.
SEE WATER SYSTEM EVALUATION CERTIFICATE OF REVIEW FOR HEALTH DEPARTMENT
RECOMMENDATIONS
I
NSPECTOR’S SIGNATURE: ______________________________________________ DATE: ___________________________
BACTERIA TEST RESULTS, (ATTACH)
LOCATION: ___________________ RESULT: ______________ DATE: ______________ INSPECTOR: ___________________
LOCATION: ___________________ RESULT: ______________ DATE: ______________ INSPECTOR: ___________________
LOCATION: ___________________ RESULT: ______________ DATE: ______________ INSPECTOR: ___________________
APPROXIMATE FLOW RATE: _______ GPM INITIAL FLOW ________GPM AFTER 35 MINTUES
LOCATION: __________________________________ IF REQUIRED: NITRATE: ___________________ MG/L
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form provided by: Stark County Health Department: Water (Stark County Government)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 14 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document