180 S. Main St., Ste. 252, Martinsville, IN 46151

765-342-6621, Fax: 765-342-1062 morgancohd@morgancountyhealth.com

Online Septic Application- Property Owner

Please Note: This application must be filled out by the property owner.

Application for Septic Permit

***This form must be completed by the Property Owner***

Type of Permit Requested:*
Real Estate Type:*
Check box for Submission of Required Documents:*
Flood Plain Designation:*
Water Source:*
Number of Bedrooms (see definition below):*

*"Bedroom" means either any room:

(1) in a residence that the local health department and the owner agree could be occupied for the purpose of sleeping and contains:

(A) an area of seventy (70) square feet or more;

(B) at least one (1) operable window or exterior door for emergency egress or rescue; and

(C) for new construction, a closet; or

(2) declared by the owner, by recorded affidavit supplied to the local health department, that will be occupied for sleeping, and that the owner further agrees within the affidavit not to occupy any additional rooms for the purpose of sleeping or otherwise represent to others that any room, beyond the number specified in the affidavit, may be utilized for sleeping without approval of the local health department. (410 IAC 6-8.3)

Number of Bathtubs Over 125 Gallons:*
Property Owner/ Applicant Name:*
E-mail:*

Email addresses are solely used as contact information and will not be shared with 3rd parties.

Mailing Address:*
Owner Phone:*
-
Alternate Phone:
-
Site Address:*
Subdivision Name:
Lot #:
Parcel #:*
Township:*
Installer Name:*
Installer Phone:*
-
Installer Address:*

Statement 1: I, the undersigned applicant, understand that I alone am responsible for the proper construction, maintenance and repair of the on-site sewage disposal system for which I have applied. An inspection of the system will be completed prior to back-filling by notifying the Morgan County Health Department. This permit is valid for 2 years from the date of issue and is nontransferable.

By checking the box below, I hereby certify that I am the applicant named above and that I agree with statement 1 above.*

Statement 2: I, the undersigned applicant, affirm under the penalties of perjury that my home is considered to be a home of the number of bedrooms stated above, as described in the bedroom definition* and accepted by the Morgan County Health Department. I understand that my septic system permit has been issued and sized correctly for my home in regard to the number of bedrooms and large bathtubs. I understand that if my septic system is not in compliance with the permit issued the permit will be null & void.

By checking the box below, I hereby certify that I am the applicant named above and that I agree with statement 2 above.*
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