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Get OK DEQ 641-581SP 2014-2023

ENVIRONMENTAL COMPLAINTS AND LOCAL SERVICES DIVISION REPORT FOR ON-SITE SEWAGE TREATMENT SOIL PROFILE DESCRIPTION TEST Work Order No. System No. Date Rec d PLEASE PRINT or TYPE GENERAL INFORMATION Name and Mailing Address of Property Owner First Name Owner Phone Number - last Name Mailing Address City Zip Code Owner s E-Mail Address Optional Property Address Oklahoma Street Address Legal Description County ft2 or Lot Size in acres Finding Location Blocks or miles from a given point Water Supply Individual Private Well Public Water Supply Name or WATERBODY PROTECTION AREA Dispersal field located in Water Body Protection Area check one Zone 1 Zone 2 or None Flow Certification 27A O. S. 2001 Section 2-6-403 states- It shall be the duty of the person contracting with an installer who is modifying or installing an on-site sewage treatment system for a residence or business to certify the number of bedrooms in the residence or the water usage of the business that will be served by the sewage treatment system so that the system can be properly sized. The following information was certified on DEQ Form 641-581cert. Certification Documentation Form This individual sewage treatment system will serve an individual residence or duplex with the following of bedrooms The estimated flow or actual flow for this small public sewage system is gal/day and is a Type of Facility SOIL TEST RESULTS No Soil Test Performed HOLE 1 Depth of Test Hole 0-6 Group Print First and Last Name of Designer HOLE 2 Limiting Layer w/in Interval HOLE 3 SEPARATION RANGE Depth of shallowest limiting layer inches Hole Most prevalent soil group found in the separation range 6-12 12-18 18-24 24-30 30-36 36-42 42-48 48 -54 Test hole with the lowest clay content in separation range DISPERSAL ALLOWED / APPLICABLE SIZING RANGE System Type Sizing Range Option Y N CSA Conventional Subsurface Absorption 12-30 LPD Low Pressure Dosing SE Shallow Extended 6-24 ET/A Evapotranspiration/Absorption L Lagoon N/A ADI Aerobic w/ Drip Irrigation 0-18 RX Redox ASI Aerobic w/Spray Irrigation RC Rock G5 Group 5 Soil RECOMMENDED SYSTEM AND SIZING CRITERIA a TREATMENT REQUIRED check one Septic tank Aerobic treatment HOLE WITH HIGHEST CLAY b CONTENT IN SIZING RANGE c MOST PREVALENT SOIL GROUP IN SIZING RANGE IN THE HOLE IDENTIFIED IN b 2a 3a CERTIFIED SOIL TESTER USE ONLY I certify that I conducted the above-described soil profile description test in compliance with OAC 252 641 on Date Test Performed Soil Tester s Signature Please Print First Name Address State Certification Number Zip Phone Date Signed DEQ USE ONLY DEQ Soil Profile Test Verification of Design Environmental Specialist s Signature Revised 7/1/2012 OR Joint Soil Profile DEQ Reviewed Certified Soil Profiler s Test Results Date Accepted Notes Employee ID Date Rejected Date Paperwork Issued DEQ Form 641-581SP Owner s Last Name SYSTEM DESIGN Check all that apply TREATMENT Septic Tank with gal. liquid capacity DISPERSAL CSA with feet of subsurface absorption trenches. .

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