RECEIPT #_______________
DATE STAMP
FEE:____________________
HUNTERDON COUNTY DEPARTMENT OF PUBLIC SAFETY
DIVISON OF PUBLIC HEALTH SERVICES
STANDARD FORM FOR SUBMISSION OF REPAIRS
A REPAIR IS THE REPLACEMENT OF ONE OR MORE COMPONENTS OF AN INDIVIDUAL SUBSURFACE
SEWAGE DISPOSAL SYSTEM IN A MANNER THAT WILL NOT CHANGE THE ORIGINAL LOCATION,
CONSTRUCTION, SIZE, CAPACITY, TYPE OR NUMBER OF COMPONENTS.
1.
PROJECT LOCATION:
MUNICIPALITY:______________________________________BLOCK:____________LOT:__________
STREET ADDRESS:___________________________________________________________________
2.
OWNER INFORMATION:
NAME OF CURRENT OWNER:__________________________________________________________
MAILING ADDRESS:___________________________________________________________________
TOWN:________________________________STATE:_____________ZIP CODE:_________________
DAYTIME PHONE:________________EVENING PHONE:_______________CELL PHONE:___________
3.
FACILITY TYPE:
RESIDENTIAL
________ NUMBER OF BEDROOMS
COMMERCIAL ______GALLONS/DAY
4.
REASON FOR REPAIR:
PONDING/BREAKOUT ONTO THE GROUND
BACKUP OF SEWAGE INTO RESIDENCE
RESULT OF SEPTIC SYSTEM INSPECTION (A COPY OF THE NJDEP ONSITE INSPECTION FORM
MUST BE ATTACHED) OR PUMPING.
SELECT FILL CLOGGED
YES
NO
5.
APPROXIMATE AGE OF SYSTEM? _____________
SEPTIC DESIGN ON FILE:
6.
NATURE OF REPAIR:
NJ TANK REPLACEMENT (type/size)____________CONCRETE__________ PLASTIC/FIBERGLASS
BAFFLE
RISER
DISTRIBUTION BOX
SPEED LEVELERS
LID
EFFLUENT FILTER OR SOLIDS RETAINER
TANK/CESSPOOL ABANDONMENT
DOSING TANK (type/size)________________________
CONNECTING LINE (SCHEDULE 40 PVC OR EQUIV.) SIZE/LENGTH ____________
BED (LWD)___________________
TRENCHES (# OF TRENCHES, LWD) ______________________
SEEPAGE PIT (SIZE)__________________________________________________________
PUMP REPLACEMENT (MUST BE RATED SAME OR EQUIVALENT HORSE POWER)
7.
PROPOSED REPAIR TO BE SKETCHED ON BACK OF THE APPLICATION. SKETCH TO INCLUDE THE
HOUSE, SEPTIC TANK, TRENCHES OR BED, WELL LOCATION, OTHER WATER COURSES AND BURIAL
SITE. PLEASE NOTE: IF REPAIR WORK IS ONLY A BAFFLE OR A RISER, THEN DISPOSAL FIELD AREA
DOES NOT NEED TO BE LOCATED ON SKETCH. ALSO, PLEASE NOTE THAT THE BURIAL SITE MUST BE
A MINIMUM OF 100' FROM ANY WELL OR THE MATERIAL SHALL BE TRANSPORTED TO A LICENSED
LANDFILL. THE WASTE LINE FROM THE HOUSE TO THE SEPTIC TANK IS NOT PART OF THE SEPTIC
SYSTEM, INSPECTION OF THIS LINE IS UNDER THE JURISDICTION OF THE MUNICIPALITY.
8.
SIGNATURE OF APPLICANT:___________________________________DATE:______________________
9.
CONTRACTOR/EXCAVATOR/INSTALLER INFORMATION:
NAME:________________________________________________ PHONE:________________________
10.
HEALTH DEPARTMENT AUTHORIZED AGENT:__________________________________________________
DATE OF APPLICATION APPROVAL:_________________
EXPIRATION DATE: ________________
*
This application approval is not to be considered a guarantee that the above mentioned repair will correct a
malfunction, only that the repair is in conformance with chapter 9A, standards for individual Subsurface
Sewage Disposal Systems.
*
An alteration may be more appropriate to correct this malfunction. This would include soil testing and a
septic design by an engineer.
PLEASE NOTE: THE APPLICANT IS RESPONSIBLE FOR OBTAINING ALL OTHER REQUIRED FEDERAL, STATE
OR LOCAL APPROVALS PRIOR TO THE COMMENCEMENT OF WORK UNDER THIS APPROVAL, INCLUDING
BUT NOT LIMITED TO, NJDEP PERMITS TO CONDUCT ACTIVITIES IN FRESHWATER WETLANDS, FRESHWATER
WETLAND TRANSITION AREAS, OR FLOOD PLANE JURISDICTIONS. FAILURE TO OBTAIN THESE PERMITS
PRIOR TO CONDUCTING REGULATED ACTIVITIES WITHIN THESE AREAS MAY RESULT IN REMOVAL OF THE
SYSTEM AND OR THE ASSESSMENT OF SIGNIFICANT CIVIL PENALTIES.