Revised 7/1/2012 DEQ FORM 641-581P
REPORT FOR ON-SITE SEWAGE TREATMENT
SOIL PERCOLATION TEST System No.
(PLEASE PRINT or TYPE) Date Rec’d
GENERAL INFORMATION:
Name and Mailing Address of Property Owner:
First Name Last Name Mailing Address City Zip Code
Owner Phone Number: ( ) - Owner’s E-Mail Address (Optional):
Property Address: , Oklahoma
Street Address City Zip Code County
Legal Description: Lot Size ft2 or acres
Finding Location:
(Blocks or miles from a given point)
Water Supply: Individual Private Well or Public Water Supply – Name:
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 PERCOLATION TEST RESULTS: No Soil Test Performed Print First and Last Name of Designer
TEST HOLE Test Hole Depth Test Hole
Percolation Rate
SHALLOWEST DEPTH AT WHICH
GROUNDWATER WAS ENCOUNTERED
OVERALL PERCOLATION RATE
#1 inches min/in inches minutes/inch
#2 inches min/in SYSTEMS ALLOWED
#3 inches min/in System Type Option based on percolation test results?
#4 inches min/in
CSA – Conventional Subsurface Absorption: Y N
#5 inches min/in L – Lagoon: Y N
#6 inches min/in ASI – Aerobic w/Spray Irrigation: Y N
Presoak Certification:
I hereby certify that I started the presoak no earlier than 24-hours prior to the start of the percolation test procedure; I did not observe water in any of the
test holes prior to starting the presoak; I presoaked each test hole by filling them with water and then refilling them as necessary to maintain a water depth
of at least 12 inches for at least 4 consecutive hours.
Printed First Name Last Name Signature Date Signed
Soil Tester Certification:
I certify that I conducted the above-described percolation test in compliance with OAC 252:641 on , and the dispersal field will
not be located in a Water Body Protection Area.
Soil Tester’s First Name Last Name Soil Tester’s Signature Date Signed
Registration # RPS RPES PE LS SS
Mailing Address Phone Number
RECOMMENDED SYSTEM: (check one)
CSA – Conventional Subsurface Absorption (requires soil test) L – Lagoon ASI – Aerobic with Spray Irrigation
DEQ USE ONLY: Percolation Test Results / Design:
ACCEPTED by DEQ on: REJECTED by DEQ on:
Date Date
Notes:
Environmental Specialist’s Signature Employee ID
Revised 7/1/2012 DEQ FORM 641-581P
System No.
Owner’s Last Name
SYSTEM DESIGN:
TREATMENT:
Septic Tank with gal. liquid capacity Aerobic Treatment
DISPERSAL:
CSA: with feet of subsurface absorption trenches. The trench bottom shall be no deeper than inches
L: with bottom dimensions of feet by feet or with a diameter of feet
ASI: with a -gallon capacity pump tank and square feet of spray irrigation area
LOCATION OF PERCOLATION TEST HOLES: (Skip this section if percolation test not performed)
REMARKS:
Show the location of all percolation test holes in relation to two fixed reference points
