Fillable RECORD OF SEWERAGE SYSTEM (Island Health)

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RECORD OF SEWERAGE SYSTEM (Island Health)

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The RECORD OF SEWERAGE SYSTEM (Island Health) form is 1 page long and contains:

  • 1 signature
  • 20 check-boxes
  • 36 other fields

Country of origin: CANADA
File type: PDF

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RECORD OF SEWERAGE SYSTEM
Filing # (OFFICE USE ONLY)
1. Property
Information
☐
New Construction
☐
Alteration
☐
Repair
☐
Amendment – Original Filing #
Tax Assessment Roll #
PID #
Legal Description (Plan, Lot, District Lot, Block Numbers)
Street (Civic) Address or General Location
City
2. Owner Information
Mailing Address
Phone
City
Prov
Postal Code
3. Authorized Person
Information
Mailing Address
Phone
City
Prov
Postal Code
Registration #
Email
4. Structure
Information
Sewerage System Will Serve:
☐
Single Family Dwelling
☐
Other Structure (specify)
☐
Other Dwelling (specify)
The sewerage system is designed for an estimated minimum daily domestic sewage flow of
(check one)
☐
Less than or equal to 9,100 litres
☐
More than 9,100 litres but less than 22,700 litres
5. Site Information
Depth of native soil to seasonal
high water table or restrictive layer (cm)
Information respecting the type, depth and porosity of the
soil is attached
☐
Yes
☐
No
GPS
Location of System (decimal degrees) Latitude Longitude
Horizontal Accuracy (m)
☐
Recreational GPS
☐
Differential GPS
6. Drinking Water
Protection
Will the sewerage system be located less than 30 m from a well?
☐
Yes
☐
No
If yes, attach a professional’s report and specify the intended distance (m)
Distance of proposed sewerage system to the closest body of surface water (m)
7. System
Information
Sewerage treatment method
☐
Type 1
☐
Type 2
☐
Type 3
8. Legal or
Regulatory
Considerations
☐
Construction of the proposed sewerage system will not
conflict with legal instruments registered on the property.
Is this filing submitted as the result of an order from the
Health Authority?
☐
Yes (attach a copy of the order)
☐
No
9. Plot Plan and
Specifications
Plot Plan (to scale) and specifications are attached
☐
Yes
☐
No
☐
The plans and specifications are consistent with Standard Practice
Source of Standard Practice:
☐
Ministry of Health Standard Practice Manual
☐
Other
10. Authorized
Person’s
Signature
Signature
OFFICE USE ONLY
Filing Accepted Date
___________________________________________________________________
Receipt Number
Date
Revised August 2015
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RECORD OF SEWERAGE SYSTEM (Island Health)

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Completed 25 November 2020

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