nkyhealth.org file · Web viewNorthern Kentucky Health Department. 8001 Veterans Memorial Drive,...
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Request for Inspection of Private Water Supply _______ Water ($200) Property to be inspected: ________________________________________________________________ STREET NUMBER _____________________________________ _______________ _______________________ CITY STATE ZIP CODE Owner’s Name: __________________________________ Owner’s Phone Number:_______________ Person making request: ___________________________ Phone number: ______________________ Address of person making request: ________________________________________________________ STREET NUMBER _____________________________________ _______________ _______________________ CITY STATE ZIP CODE TO EXPEDITE PROCESS: On reverse side of sheet, include a drawing of the property showing location of house, septic tank/system, cistern or well, driveway, outbuildings, or related structures and landmarks. Source of water supply: Cistern _________ Well_________ City_________ Other _________ Construction of cistern or well: _________ Date cistern last cleaned: ______ Disinfected: ________ Is water routinely chemically treated? Yes _____ No _____ Unknown _____ Is water supply filtered? Yes _____ No _____ Unknown _____ If Yes, type of filtration?____________ Is water supply turned on to home? Yes _____ No _____ Unknown _____ Northern Kentucky Health Department 8001 Veterans Memorial Drive, Florence, KY 41042| 859-341-4151 | www.nkyhealth.org
Transcript of nkyhealth.org file · Web viewNorthern Kentucky Health Department. 8001 Veterans Memorial Drive,...
Request for Inspection of Private Water Supply_______ Water ($200)
Property to be inspected: ________________________________________________________________STREET NUMBER
_____________________________________ _______________ _______________________ CITY STATE ZIP CODE
Owner’s Name: __________________________________ Owner’s Phone Number:_______________
Person making request: ___________________________ Phone number: ______________________
Address of person making request: ________________________________________________________STREET NUMBER
_____________________________________ _______________ _______________________ CITY STATE ZIP CODE
TO EXPEDITE PROCESS: On reverse side of sheet, include a drawing of the property showing location of house, septic tank/system, cistern or well, driveway, outbuildings, or related structures and landmarks.
Source of water supply: Cistern _________ Well_________ City_________ Other _________
Construction of cistern or well: _________ Date cistern last cleaned: ______ Disinfected: ________
Is water routinely chemically treated? Yes _____ No _____ Unknown _____
Is water supply filtered? Yes _____ No _____ Unknown _____ If Yes, type of filtration?____________
Is water supply turned on to home? Yes _____ No _____ Unknown _____
Is outside water spigot active/available for collecting water sample? Yes _____ No _____ Unknown ____
Is the cistern inspection manhole accessible and easily removed? Yes _____ No ____ Unknown _____
Is septic tank lid/riser visible? Yes _____ No _____ Unknown _____
I have read the private water cover letter and understand the scope of the inspection and sampling.
_____________________________________________ __________________________________SIGNATURE OF APPLICANT DATE
Office use only Date received: ________ By: ____________________ Paid by: _____ Cash _____Check #(_____)
_____ Money order # (______________________) _____ Credit/Debit card
Revised June 2019
Northern Kentucky Health Department8001 Veterans Memorial Drive, Florence, KY 41042| 859-341-4151 | www.nkyhealth.org
