Parke County Health Dept. APPLICATION FOR ONSITE
116 W. High St., Room 12 SEWAGE SYSTEM PERMIT
Rockville, IN 47872
Phone (765) 569-4071 ______ NEW SYSTEM ______REPAIR _____EXPANSION
Fax (765) 569-4061 ______ RE-CONNECTION _______ REPLACEMENT
Please complete the information on this page:
Owner’s Name _________________________________________________Phone ______________________________
Owner’s mailing address _____________________________________________________________________________
City __________________________________ State________________ Zip Code _________________
E-mail Address_____________________________________________________________________________________
Site Address: ______________________________________________________________________________________
City __________________________________ State_______________ Zip Code___________________
We will need a copy of the deed.
Water supply: __________City___________County ______________ Well _______________Spring ___________Other
Number of bedrooms _____________ Number of bathrooms ______________ Number of people in house __________
Number of jetted bathtubs (whirlpool-type 125 Gal & over) ___________ Est. Sq. Footage of House _________________
Name, address, phone# of installer______________________________________________________________________
Name, address, phone# of builder ______________________________________________________________________
$75 non-refundable application fee is required before a permit can be issued. This is an application only, not a
permit.
I have read this application and hereby certify that, to the best of my knowledge, the information on this sheet is correct. In addition, the water supply and sewage
facilities for this building will be installed strictly in accordance with all provisions of Indiana State Law 410 IAC 6-8.3, and with the Parke County Sewage Disposal
Ordinance. I will allow Parke County Health Department personnel onto the property at any time for inspections of the septic system.
A permit may be revoked by the Parke County Health Department for failure to comply with Indiana State Department of Health Rule 410 IAC 6-8.3 and/or any
other applicable regulations. (Revocation of the permit shall be in writing to the property owner and/or their agent; shall state the reasons for revoking the permit;
remedial actions necessary; and upon written request afford the applicant the opportunity for a fair hearing.)
Applicant’s Signature _________________________________________ Date _______________________________
DIRECTIONS to site:
_____________________________________________________________________________________________
Nearest crossroads: ____________________________________Distance to property________________________
Nearest mailbox number: _______________________________Distance to property________________________
Landmarks noticeable from road (i.e. buildings, ponds, etc.) ____________________________________________
