SUBDIVISION / LOT SPLIT FORM
Note: It is intended that the most cost-effective means of ensuring Sewage Treatment System (STS) suitability are used.
The larger the acreage the less the necessity of conducting an intensive study. At a minimum, the property will be
reviewed for adequate soils, suitable topography, and enough length and width along the contour for an STS.
ONLY THOSE DIVISIONS SUBDIVIDED UNDER O.R.C. 711.131 OR 711.133 NEED HEALTH DEPARTMENT APPROVAL
Fees do not need to be submitted up-front, but must be paid prior to release of this paperwork. It may not be known
which fee listed below is applicable until the plat has been studied.
OFFICE USE ONLY
$60.00 Addition Evaluation
Use this fee when there is an existing structure with a STS that must be
evaluated. Evaluation determines: if system is operating properly; if
system will cross any proposed property lines; and if adequate replacement
area is available.
$150.00 per vacant lot, subdivision review
Use this fee to determine if lots, part of major or minor subdivisions, have
adequate space and soils for STS’s. Soil tests are needed when parcels are
less than 5 acres in size.
There is no fee for a lot or lots that have been previously assessed a fee.
$ _____________
Total Amount
__________________
Date Paid
___________________________________________________
Sanitarian Name
CUSTOMER: Please fill out when dropping off spilt.
Owner Name
Phone #
Applicant Name Company Name
Township of Property to be Split
Phone number for pickup or questions
