Onsite Wastewater Site Assessment

Onsite Wastewater Site Assessment
Instructions

Please read these instructions before you continue to the next page to fill out the application.
The wastewater drainfield area needs to be determined before any other plans are made. The following items must be completed before a site assessment can be done:

1. Consult with the planning and zoning department in your area to determine land use restrictions.

2. Consult with water and sewer districts in your area about connecting to public sewer and water. *You are required to connect to public sewer if it is available within 300 feet of the property line.

3. Dig soil exploration hole(s). Click for instructions.

4. Submit soil log completed by a certified individual and percolation test if required.

5. Draw details (as per instructions below) on the plat obtained from your county recorder's office.

6. Fill out the request form completely.

7. All of the following must be submitted before the request will be accepted:
- Request Form (submitted on next page)
- County plat of lot with details
- Soil Log
- Percolation test results (if required)
- Exploration hole(s) dug
- Fee $250 (submitted with Request Form on next page)
- Tax ID Form: Copy of property tax statement or print-out from the county showing legal description and property serial # or tax I.D. #.

Plat Instructions
Get a copy of the property plat with property lines and dimensions from the county recorder's office. Indicate all of the following information on the plat:
- Location of soil exploration holes and percolation tests (if required). Indicate exact distance and direction from nearest property corner. Please note: The inspector should be able to locate all of the property corners on site.
- Distance from property line to nearest public sewer and public water, and size of service lines.
- Location of all existing and/or proposed private water sources within 200 feet, and all public water sources within 1500 feet of exploration hole(s).
- Location of easements or drainage right-of-ways affecting the property.
- Location of all streams, ditches, watercourses, ponds, subsurface drains, etc. within 200 feet of exploration hole(s).
Upload the completed plat here (if it is too large to upload please bring it to TriCounty Health Department in Roosevelt or Vernal).

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Site Assessment Request
For Division of Property?
Graywater System?
Property Serial #
Date

MonthDayYear
Date
Total Lot Acreage
Applicant Name

First NameLast Name
Email
example@example.com
Daytime Phone #
Format: (000) 000-0000.
Cellular Phone (if different)
Format: (000) 000-0000.
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the applicant also the property owner?
Property Owner

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Property Address to be Inspected

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Upload a map here if there is no street address.

Please include easy to find landmarks and 1/10 mile odometer readings for every turn. For any gates, keys or combinations must be provided to the inspector. Failure to do so may result in a delay in processing your application and an extra visit fee of $250.
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Upload Soil Log/ Perc Test Here

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Please draw a map here if there is no street address. Please include easy to find landmarks and 1/10 mile odometer readings for every turn. For any gates, keys or combinations must be provided to the inspector. Failure to do so may result in a delay in processing your application.
Drinking Water Source
Reason for site assessment
Structure to be built
# of bedrooms
Commercial Use (if applicable)
# of Employees (if applicable)

Site Assessment

$250.00

Total

Instructions