Southwestern District Health Unit
227 16
Street West, Dickinson, North Dakota 58601
Telephone: (701) 483-0171 Toll Free: 1-800-697-3145 Fax: (701) 483-4097
Type of Facility:
Residential Home / Cabin (# of bedrooms
_______) Residential Garage / Shop Man Camp
Commercial / Industrial Shop RV / Trailer Park Office Building Other
Minimum lot size for an onsite sewer system is 40,000 square feet.
If the system will be used by 25 or more people on a daily basis, have greater than 14 service connections, or for RV parks, have
greater than 12 RV hook-ups, the plans will have to be approved by the ND Department of Health.
General Information:
__________ Mail or Rural Address: __________ City: ________________________________
Legal Description: ____________________________ County:
__________ Lot #: _____ Block: _____
Subdivision: _________________________ **Maximum number of people that will use the system daily:
System Type: Septic Tank / Drainfield Holding Tank
Septic Tank: (1000 gallon working capacity minimum.) Size:
__________ gallons Number of Tanks: _____
Material: __________
Distance from: Foundation:
_____ ft. Well: _____ ft. (50 ft. minimum for wells 100 ft. deep, or deeper if well is under 100 ft.
deep, 100 ft. distance or greater is required)
Lake / Stream / High Water Level
_____ ft. (100 ft. minimum)
Percolation Test or Soil Type:
__________ Lift Pump: YES NO Diameter of Chamber: _____
Drainfield Information (if allowed): Type: Gravel-less Rock/Perforated Tile
Distance From: Septic Tank:
_____ ft. (10 ft. minimum) Stream/Lake/Drainage _____ ft. (100 ft. minimum)
Property Line:
_____ ft. (10 ft. minimum)
Length of Drainfield Tile:
_____ ft. (200 ft. minimum for gravel-less) Trench Width: _____
Width of Drainage Pipe/Chamber:
Depth of Pipe (top of pipe/chamber to surface)
_____ in. (30 to 36 inches maximum- total trench depth should not exceed 48”)
Depth of Rock under Perforated Pipe:
_____ Size of Rock: _____ (washed gravel or crushed stone- No scoria allowed)
Total Amount of Absorption Area in Square Feet (length X width) _____ sq. ft.
Please complete the information on the next page.
Well Information: Type: Drilled Dug Bored Community System
Depth: _____ Diameter: _____
Distance from: Sewer:
_____ ft. (50 ft. minimum for wells 100 ft. deep or deeper, if well is under 100 ft. deep 100 ft. distance or
greater is required.) Foundation:
Property Line:
_____ Buried Tanks: _____ Body of Water: _____
Draw a diagram of the proposed or existing sewer and water system. Please make the drawing as accurate as possible. Must
include the locations of the building, well, septic tank, lift pump, drainfield, and any sources of contamination. *Please note some of
the minimum & maximum distances on the front of the application. Be aware of topographical features. Sewer systems should not
be installed in low-lying areas subject to flooding or areas subject to heavy water runoff. In areas of heavy soils or high water tables,
the size of the drain field may need to be increased beyond that indicated on these plans.
** Area over the drainfield should have topsoil, seeded into grass and not be driven on to avoid compaction**
I hereby submit the above information to be correct as to present or proposed installation:
Signature: _____________________________________ Installer: _______________________________________
_____________________________________ Address: ___________________________________
_____________________________________ Zip: _________ Phone #: _______________________
The proposed sewer and/or water system plans are hereby approved and subject to an onsite inspection before covering. This is
only a plan approval; an onsite inspection is required for final approval. The Southwestern District Health Unit accepts no
responsibility for systems that are designed improperly or not inspected at the time of installation.
____________________________________________ ________________________________________________
(Date of Application) (EHP signature for pre-approval)
(Inspection may be required)
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