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Application For Permit To Construct A Private Sewage Disposal System Form - Adams County Health Department Page 2

LAYOUT SKETCH

Show: Lot, house, sewage system, distance to water line, water wells (existing or proposed) including

wells on adjoining properties and show all dimensions.

REMARKS:_________________________________________________________________________________

__________________________________________________________________________________________

DATE:_________________Signed_______________________________________Approved Y ( )

N ( )

Representative of Board of Health

IMPORTANT

The Adams County Health Department does not warranty proper operation of the sewage treatment and/or disposal system contemplated herein

by issuance of a sewage permit, or by final approval. The contractor and/or persons other than the Adams County Health Department are

responsible for proper installation of the sewage treatment and/or disposal system contemplated herein, and for compliance with Adams County

Health Department’s Ordinance and other applicable laws. The Adams County Health Departments does not assume responsibility or liability for

any nuisance and/or health hazard that may arise due to improper installation or operation of work performed pursuant to this permit.

Application For Permit To Construct A Private Sewage Disposal System Form - Adams County Health Department Page 2