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Maine Dept.Health & Human ServicesDiv of Environmental Health , 11 SHS(207) 287-5672 Fax: (207) 287-4172SUBSURFACE WASTEWATER DISPOSAL SYSTEM APPLICATIONPROPERTY LOCATION CAUTION: LPI APPROVAL REQUIRED City, Town,or PlantationTown/CityPermit #Street or RoadDate Permit Issued / /Subdivision, Lot #Fee: Double Fee Charged [ ]Local Plumbing Inspector SignatureL.P.I. #OWNER/APPLICANT INFORMATIONName (last, first, MI)[OwnerApplicantOwner[Town[StateThe Subsurface Wastewater Disposal System shall not be installed until aPermit is issued by the Local Plumbing Inspector. The Permit shallMailing Address ofOwner/Applicantauthorize the owner or installer to install the disposal system in accordancewith this application and the Maine Subsurface Wastewater Disposal Rules.Municipal Tax Map #Daytime Tel. #CAUTION: INSPECTION REQUIREDI have inspected the installation authoirzed above and found it to be in compliancewith the Subsurface Wastewater Disposal Rules Application.(1st) date approvedOWNER OR APPLICANT STATEMENTI state and acknowledge that the information submitted is correct to the best ofmy knowledge and understand that any falsification is reason for the Departmentand/or Local Plumbing Inspector to deny a Permit.Signature of Owner or ApplicantLot #DateLocal Plumbing Inspector Signature(2nd) date approvedPERMIT INFORMATIONTYPE OF APPLICATIONTHIS APPLICATION REQUIRES1. No Rule Variance1. First Time System2. Replacement System2. First Time System Variancea. Local Plumbing Inspector Approvalb. State & Local Plumbing Inspector ApprovalType replaced:Year installed:3. Replacement System Variance3. Expanded Systema. 25% Expansionb. 25% Expansiona. Local Plumbing Inspector Approvalb. State & Local Plumbing Inspector Approval4. Experimental System4. Minimum Lot Size Variance5. Seasonal Conversion5. Seasonal Conversion PermitSIZE OF PROPERTYSQ. FT.ACRESSHORELAND ZONINGYesNoDISPOSAL SYSTEM TO SERVE1. Single Family Dwelling Unit, No. of Bedrooms:2. Multiple Family Dwelling, No. of Units:3. Other:(specify)Current Use Seasonal Year Round UndevelopedDISPOSAL SYSTEM COMPONENTS1. Complete Non-engineered System2. Primitive System (graywater & alt. toilet)3. Alternative Toilet, specify:4. Non-engineered Treatment Tank (only)5. Holding Tank, gallons6. Non-engineered Disposal Field (only)7. Separated Laundry System8. Complete Engineered System (2000 gpd or more)9. Engineered Treatment Tank (only)10. Engineered Disposal Field (only)11. Pre-treatment, specify:12. Miscellaneous ComponentsTYPE OF WATER SUPPLY1. Drilled Well4. Public2. Dug Well3. Private5. OtherDESIGN DETAILS (SYSTEM LAYOUT SHOWN ON PAGE 3)TREATMENT TANK1. Concretea. Regularb. Low Profile2. Plastic3. Other:CAPACITY: GAL.SOIL DATA & DESIGN CLASSPROFILE CONDITION/at Observation Hole #Depth "of Most Limiting Soil FactorDISPOSAL FIELD TYPE & SIZE1. Stone Bed 2. Stone Trench3. Proprietary Devicea. cluster array c. Linearb. regular load d. H-20 load4. Other:SIZE: sq. ft. lin. ft.DISPOSAL FIELD SIZINGGARBAGE DISPOSAL UNIT1. No 2. Yes 3. MaybeIf Yes or Maybe, specify one below:a. multi-compartment tankb. tanks in seriesc. increase in tank capacityd. Filter on Tank OutletDESIGN FLOWgallons per dayBASED ON:1. Table 4A (dwelling unit(s))2. Table 4C(other facilities)SHOW CALCULATIONS for other facilites3. Section 4G (meter readings)ATTACH WATER METER DATAEFFLUENT/EJECTOR PUMP1. Not Required1. Medium---2.6 sq. ft. / gpd2. Medium---Large 3.3 sq. f.t / gpd3. Large---4.1 sq. ft. / gpd4. Extra Large---5.0 sq. ft. / gpd2. May Be RequiredLATITUDE AND LONGITUDEat center of disposal areaLat. d m sLon. d m sif g.p.s, state margin of error:3. RequiredSpecify only for engineered systems:DOSE: gallonsSITE EVALUATOR STATEMENTI certify that on (date) I completed a site evaluation on this property and state that the data reported are accurate andthat the proposed system is in compliance with the State of Maine Subsurface Wastewater Disposal Rules (10-144A CMR 241).Site Evaluator SignatureSite Evaluator Name PrintedSE #Telephone NumberNote : Changes to or deviations from the design should be confirmed with the Site Evaluator.DateE-mail AddressPage 1 of 3HHE-200 Rev. 08/2011

SUBSURFACE WASTEWATER DISPOSAL SYSTEM APPLICATIONTown, City, PlantationStreet, Road, SubdivisionSITE PLANDepartment of Human ServicesDivision of Health Engineering(207) 287-5672 Fax: (207) 287-3165Owner's NameScale 1" ft. or as shownSITE LOCATION PLAN(map from Maine Atlasrecommended)SOIL DESCRIPTION AND CLASSIFICATION (Location of Observation Holes Shown Above)Observation HoleTest PitBoring" Depth of Organic Horizon Above Mineral SoilTextureConsistencyColorObservation HoleTest PitBoring" Depth of Organic Horizon Above Mineral SoilTextureMottlingConsistencyColorMottling0Depth Below Mineral Soil Surface (inches)Depth Below Mineral Soil Surface (inches)010203040501020304050Soil ClassificationProfile ConditionSlopeLimitingFactor%"[[[[] Ground Water] Restrictive Layer] Bedrock] Pit DepthSoil ClassificationProfile ConditionSlopeLimitingFactor%"[[[[] Ground Water] Restrictive Layer] Bedrock] Pit DepthPage 2 of 3HHE-200 Rev. 02/11Site Evaluator SignatureSE #Date

SUBSURFACE WASTEWATER DISPOSAL SYSTEM APPLICATIONTown, City, PlantationStreet, Road, SubdivisionSITE PLANDepartment of Human ServicesDivision of Health Engineering(207) 287-5672 Fax: (207) 287-3165Owner's NameScale 1" ft. or as shownSITE LOCATION PLAN(map from Maine Atlasrecommended)SOIL DESCRIPTION AND CLASSIFICATION (Location of Observation Holes Shown Above)Observation HoleTest PitBoring" Depth of Organic Horizon Above Mineral SoilTextureConsistencyColorObservation HoleTest PitBoring" Depth of Organic Horizon Above Mineral SoilTextureMottlingConsistencyColorMottling0Depth Below Mineral Soil Surface (inches)Depth Below Mineral Soil Surface (inches)010203040501020304050Soil ClassificationProfile ConditionSlopeLimitingFactor%"[[[[] Ground Water] Restrictive Layer] Bedrock] Pit DepthSoil ClassificationProfile ConditionSlopeLimitingFactor%"[[[[] Ground Water] Restrictive Layer] Bedrock] Pit DepthPage 2 of 3HHE-200 Rev. 8/01Site Evaluator SignatureSE #Date

SUBSURFACE WASTEWATER DISPOSAL SYSTEM APPLICATIONTown, City, PlantationStreet, Road, SubdivisionDepartment of Human ServicesDivision of Health Engineering(207) 287-5672 Fax: (207) 287-3165Owner's NameSUBSURFACE WASTEWATER DISPOSAL PLAN0SCALE: 1" FT.FILL REQUIREMENTSDepth of Fill (Upslope)CONSTRUCTION ELEVATIONSFinished Grade ElevationTop of Distribution Pipe or Proprietary DeviceELEVATION REFERENCE POINTLocation & Description:Reference Elevation:Depth of Fill (Downslope) Bottom of Disposal AreaDISPOSAL AREA CROSS SECTIONScaleHorizontal 1" ft.Vertical1" ft.Page 3 of 3HHE-200 Rev. 02/11Site Evaluator SignatureSE #Date

SUBSURFACE WASTEWATER DISPOSAL SYSTEM APPLICATIONTown, City, PlantationStreet, Road, SubdivisionDepartment of Human ServicesDivision of Health Engineering(207) 287-5672 Fax: (207) 287-3165Owner's NameSUBSURFACE WASTEWATER DISPOSAL PLAN0SCALE: 1" FT.FILL REQUIREMENTSDepth of Fill (Upslope)CONSTRUCTION ELEVATIONSFinished Grade ElevationTop of Distribution Pipe or Proprietary DeviceELEVATION REFERENCE POINTLocation & Description:Reference Elevation:Depth of Fill (Downslope) Bottom of Disposal AreaDISPOSAL AREA CROSS SECTIONScaleHorizontal 1" ft.Vertical1" ft.Page 3 of 3HHE-200 Rev. 02/11Site Evaluator SignatureSE #Date

SUBSURFACE WASTEWATER DISPOSAL SYSTEM APPLICATIONTown, City, PlantationStreet, Road, SubdivisionDepartment of Human ServicesDivision of Health Engineering(207) 287-5672 Fax: (207) 287-3165Owner's NameSUBSURFACE WASTEWATER DISPOSAL PLAN0SCALE: 1" FT.CONSTRUCTION ELEVATIONSFILL REQUIREMENTSDepth of Fill (Upslope)Finished Grade ElevationTop of Distribution Pipe or Proprietary DeviceELEVATION REFERENCE POINTLocation & Description:Reference Elevation:Depth of Fill (Downslope) Bottom of Disposal AreaDISPOSAL AREA CROSS SECTIONScaleHorizontal 1" ft.Vertical1" ft.3"EXISTING GRADE12"LEVEL6"Page 3 of 3HHE-200 Rev. 02/11Site Evaluator SignatureSE #Date

Department of Human ServicesDivision of Health Engineering(207) 287-5672 Fax: (207) 287-3165Owner's NameSUBSURFACE WASTEWATER DISPOSAL SYSTEM APPLICATIONTown, City, PlantationStreet, Road, SubdivisionSUBSURFACE WASTEWATER DISPOSAL PLAN0SCALE: 1" FT.CONSTRUCTION ELEVATIONSFILL REQUIREMENTSDepth of Fill (Upslope)Finished Grade ElevationTop of Distribution Pipe or Proprietary DeviceELEVATION REFERENCE POINTLocation & Description:Reference Elevation:Depth of Fill (Downslope) Bottom of Disposal AreaDISPOSAL AREA CROSS SECTIONScaleHorizontal 1" ft.Vertical1" ft.3"3'3112"LEVEL6"6"Page 3 of 3HHE-200 Rev. 02/11Site Evaluator SignatureSE #Date

SUBSURFACE WASTEWATER DISPOSAL SYSTEM APPLICATIONTown, City, PlantationStreet, Road, SubdivisionDepartment of Human ServicesDivision of Health Engineering(207) 287-5672 Fax: (207) 287-3165Owner's NameSUBSURFACE WASTEWATER DISPOSAL PLAN0SCALE: 1" FT.CONSTRUCTION ELEVATIONSFILL REQUIREMENTSDepth of Fill (Upslope)Finished Grade ElevationTop of Distribution Pipe or Proprietary DeviceELEVATION REFERENCE POINTLocation & Description:Reference Elevation:Depth of Fill (Downslope) Bottom of Disposal AreaDISPOSAL AREA CROSS SECTIONScaleHorizontal 1" ft.Vertical1" ft.3"EXISTING GRADE12"LEVELLEVEL6"Page 3 of 3HHE-200 Rev. 02/11Site Evaluator SignatureSE #Date

SUBSURFACE WASTEWATER DISPOSAL SYSTEM APPLICATIONTown, City, PlantationStreet, Road, SubdivisionDepartment of Human ServicesDivision of Health Engineering(207) 287-5672 Fax: (207) 287-3165Owner's NameSUBSURFACE WASTEWATER DISPOSAL PLAN0SCALE: 1" FT.CONSTRUCTION ELEVATIONSFILL REQUIREMENTSDepth of Fill (Upslope)Finished Grade ElevationTop of Distribution Pipe or Proprietary DeviceELEVATION REFERENCE POINTLocation & Description:Reference Elevation:Depth of Fill (Downslope) Bottom of Disposal AreaDISPOSAL AREA CROSS SECTIONScaleHorizontal 1" ft.Vertical1" ft.3"3'3112"LEVEL6"Page 3 of 3HHE-200 Rev. 02/11Site Evaluator SignatureSE #Date

SUBSURFACE WASTEWATER DISPOSAL SYSTEM APPLICATIONTown, City, PlantationStreet, Road, SubdivisionDepartment of Human ServicesDivision of Health Engineering(207) 287-5672 Fax: (207) 287-3165Owner's NameSUBSURFACE WASTEWATER DISPOSAL PLAN0SCALE: 1" FT.CONSTRUCTION ELEVATIONSFILL REQUIREMENTSDepth of Fill (Upslope)Finished Grade ElevationTop of Distribution Pipe or Proprietary DeviceELEVATION REFERENCE POINTLocation & Description:Reference Elevation:Depth of Fill (Downslope) Bottom of Disposal AreaDISPOSAL AREA CROSS SECTIONScaleHorizontal 1" ft.Vertical1" ft.3"3'3112"6"6"Page 3 of 3HHE-200 Rev. 02/11Site Evaluator SignatureSE #Date

(map from Maine Atlas recommended) SOIL DESCRIPTION AND CLASSIFICATION (Location of Observation Holes Shown Above) Page 2 of 3 HHE-200 Rev. 02/11 Observation Hole _ Test