Onsite Sewage Facility Application and Inspection Report
Asterisks (*) indicate required fields
NoticeAFTER APPROVAL A BUILDING PERMIT MUST BE SECURED FROM THE APPROPRIATE COUNTY OR CITY BUILDING INSPECTION DEPARTMENT. The final inspection is to assure the system has been constructed according to the submitted plan and is consistent with good public health engineering practices. The acceptance of this plan and the approval of the final inspection, however, should not be construed to mean that the Galveston County Health District recommends, approves, certifies or guarantees On-site Sewage Facility Systems or their satisfactory performance. In the Galveston County area, due to the high water table, variation of water usage, soil and climate conditions, On-site Sewage Facility Systems may not function satisfactorily at all times. This plan meets all State and local rules and laws including distance requirements.
Application date* Application type*
Owner Name (Last, First MI)*
Daytime Phone*Email*
Permanent Mailing Address*
Site Address*
Property Description
Lot Size*Property Survey*

Water Source*
Private Well
Public Water Supply
Other Supplier
Other Supplier
Single Family Residence
No. of BedroomsLiving Area (sq ft)

Estimated maximum water consumption (gpd)*
Water Saving Devices*
Commercial/Institutional (including multi-family residences)
No of Employees/Occupants/Units
Days occupied per week

Is an organized sewage collection within 300 feet?*

Professional design required*
If yes, professional design attached
Professional design attachment

Professional designer
Registration NoPhone

Phone*Registration No*
Sewer (House Drain)
Type and size of pipeSlope of sewer pipe to tank
Treatment Tanks
Tank Material No of CompartmentsTypeSize (gal)
Site Evaluation
Soil Class/TextureLoad Rate
Performed ByPhone
Disposal Area
TypeMinimum area required
Excavation widthDistance between excavations
Type/Size of MediaType/Diameter of Pipe
Barrier typeExcavation depth
Landscape plan

Plot Plan*

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