Sewage System Addition Evaluation
7235 Whipple Ave NW Suite B● North Canton, OH 44720 ● Phone (330) 493-9904 ● Fax (330) 493-9920 ● www.starkhealth.org
PROPERTY ADDRESS:_____________________________________________________________________TOWNSHIP: ________________________________________
CITY:________________________________________________________ZIP:__________________________OWNER:____________________________________________
PERSON RESPONSIBLE FOR ACCESS & TITLE: _____________________________________________PHONE #:__________________________________________
When completed, would you like this form e-mailed? Y N E-MAIL TO:_____________________________________________________________
Is home connected to sanitary sewer? Y N Is home connected to municipal water? Y N
Has the septic system been inspected by the Health Department within the past year? Y
N If yes, check which type below:
Property Transfer
Type of Improvements
to be made:
Will excavation OR grading be necessary?
N If yes, please describe:
Size and description of addition: _____________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
A diagram of the improvements must accompany this form. Minimally show the house, addition(s), driveway, well, and septic tank location with dimensions.
●
Current layout of property can be obtained from the Stark County Auditor’s Website—http://starkcountyohio.gov/auditor.
●
Septic and water well records can be obtained from
www.starkhealth.org.
●
Submit completed form to online@starkhealth.org
Health Department Use Only
Field located components Unable to locate some components In office records review
SATISFACTORY, date:_____________________________Based on the information provided by the applicant, the proposed addition or split will not
interfere with the location of the septic system, future replacement area, or water well.
UNSATISFACTORY, date:__________________________The proposed addition or split interferes with the septic system, future replacement area,
or water well. The proposal must be relocated/altered or a variance must be obtained from the Board of Health.
UNSATISFACTORY, date:__________________________The septic system has failed inspection. It will need to be repaired or replaced. Contact
the Health Department to make arrangements for an site evaluation.
FURTHER ACTIONS TAKEN, NOW SATISFACTORY, date:____________________________________
COMMENTS: __________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
Sanitarian Signature:__________________________________________________ Date:_______________________________________________
Page 1 of 2
Deck/Porch
Bedrooms
Property Split
New Installation
Bathroom(s)
Pool
Property Split
Out-building
Y
Addition Evaluation
Living Space
Shed
click to sign
signature
click to edit
![]()
