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Site & Soil Evaluation Application Goldendale Office Klickitat County Health Department White Salmon Office 115 W. Court St Monday-Friday, 8am to 5pm 501 NE Washington St/ PO Box 159 Box 103 White Salmon, WA 98672 Goldendale, WA 98620 [PHONE REDACTED] [PHONE REDACTED] To obtain approval for a new or replacement on-site septic system you must submit a complete site evaluation application. This evaluation is an examination of the soil profiles in the test pits where the dispersal component will be located. Before you apply, ensure you have acquired your parcel number. You may contact the Assessor’s office if you do not have a parcel number for this application, (509) 773-3715. If this site evaluation is for a waterless toilet installation permit, contact your sanitarian. The first step is to hire an excavator to dig the perc holes, but if you have the proper equipment, you may dig the holes yourself. Remember to call 811 for locates before you dig! For new installations, dig two holes for the primary dispersal area and two holes for the reserve area, four total. The test pits should be dug approximately 50 feet apart from each other and no more than 100 feet. All test pits should be 100 feet away from wells & surface water. If the area is sloped, dig two holes upslope and two downslope. For repairs or expansions, two test pits are sufficient. More complex sites may require additional test pits. You must clearly mark or flag the following areas prior the site visit; proposed home location, any additional structures, existing well or proposed well location, any existing utilities or easements, or any access locations. Once the holes are dug, turn in the site evaluation application with the fee of $500. Once submitted you can call to schedule the site & soil evaluation. You can also ask to have the sanitarian present during the excavation of the holes as well. Reports may take up to two weeks to be completed after the test pits are evaluated. The site evaluation is nonrefundable once services are rendered. If high water conditions are present, the sanitarian may request a wet season evaluation per WAC 246-272a-0220(4). To ensure sanitarian safety, follow the diagram below when constructing the soil test pits. If the site is particularly wet or saturated, please construct a stepped entrance. Avoid digging the test pits in the following areas; swales or landform depressions, slopes greater than 45 percent, areas that have been previously excavated and filled, areas where groundwater may surface during the wet season, and areas that will be used for development (homesite, roads, outbuildings, etc.). During excavation any large equipment must be shut down when a person is in the test pit. ---PAGE BREAK--- Goldendale Office Klickitat County Health Department White Salmon Office 115 W. Court St Monday-Friday, 8am to 5pm 501 NE Washington St/ PO Box 159 Box 103 White Salmon, WA 98672 Goldendale, WA 98620 [PHONE REDACTED] [PHONE REDACTED] Applicant and Site Information Name: Mailing Address: City: State: Zip: Phone: Email: Property Owner: Tax Parcel Number: Site Address: Directions to the property: Access Restrictions (gate code, dogs, cattle): Project Proposal / Wastewater Source ☐Residential ☐Multi-Family ☐Commercial ☐Food Service Other: Proposed Water Supply ☐Existing ☐New ☐Future Drinking Water Source ☐Well ☐Spring ☐Shared Well ☐Public Water System: Owner/Applicant Statement: I, the undersigned, hereby certify that the information provided is true and accurate to the best of my knowledge. I hereby assume all responsibility for the accuracy of the information contained herein and grant Klickitat County Health Department staff permission to enter the above listed property for the purpose of this application. Signature: Date: Health Department Use Only Date Received: SmartGov Case Perc Holes Ready? Receipt Number: Assigned to: ---PAGE BREAK--- Goldendale Office Klickitat County Health Department White Salmon Office 115 W. Court St Monday-Friday, 8am to 5pm 501 NE Washington St/ PO Box 159 Box 103 White Salmon, WA 98672 Goldendale, WA 98620 [PHONE REDACTED] [PHONE REDACTED] Please indicate the following on the site plan sketch. □ Building size and location □ Driveway □ Water system pipes □ All domestic water supplies (wells) □ Bodies of water □ Property size □ Property lines □ Distance from structures and out buildings □ Distance from wells □ Distance from other sewage system components □ Desired area for sewage system and reserve area □ Location of test pits □ All legal easements on the property □ Direction of slope □ Grade of slope (expressed in degrees or percent) □ Adjacent roads Please provide some preliminary information regarding the site. See example on the next page. Vicinity Sketch (directions to the property) Tax parcel # Draw your site plan. If the property is less than 2 acres, the plan must be to scale. Examples are on the next page. ---PAGE BREAK--- Goldendale Office Klickitat County Health Department White Salmon Office 115 W. Court St Monday-Friday, 8am to 5pm 501 NE Washington St/ PO Box 159 Box 103 White Salmon, WA 98672 Goldendale, WA 98620 [PHONE REDACTED] [PHONE REDACTED] ---PAGE BREAK--- Goldendale Office Klickitat County Health Department White Salmon Office 115 W. Court St Monday-Friday, 8am to 5pm 501 NE Washington St/ PO Box 159 Box 103 White Salmon, WA 98672 Goldendale, WA 98620 [PHONE REDACTED] [PHONE REDACTED] Minimum Horizontal Setbacks Items requiring setback From edge of soil dispersal and reserve area From sewage tank and distribution box From building sewer, and nonperforated distribution pipe Well 100ft 50ft 50ft Public drinking water well 100ft 100ft 100ft Nonpublic drinking water well 100ft 50ft 50ft Public drinking water spring or surface water measured from the ordinary high-water mark 200ft 200ft 100ft Nonpublic drinking water spring or spring or surface water measured from the ordinary high-water mark₁ 100ft 50ft 50ft Nonpublic, in-ground, drinking water containment vessel₃ 20ft 10ft 10ft Pressurized water supply line or easement for water supply line 10ft 10ft 10ft Closed geothermal loop₄ or pressurized nonpotable water line 10ft 10ft 10ft Decommissioned well in accordance with chapter 173-160 WAC 10ft N/A N/A Surface water measured from the ordinary high-water mark 100ft 50ft 10ft Building foundation / in-ground swimming pool 10ft 5ft 2ft Property or easement line 5ft 5ft N/A Lined₅ stormwater detention pond₆ Down-gradient₇: 30ft N/A N/A Up-gradient₇: 10ft N/A N/A Unlined₈ stormwater infiltration pond₆ (up or down-gradient)₇ 100ft 50ft 10ft Irrigation canal or irrigation pond (up or down-gradient) 100ft 50ft 10ft Interceptor/curtain drains/foundation drains/drainage or seasonal irrigation ditches Down-gradient₂: 30ft 10ft N/A Up-gradient₂: 10ft 10ft N/A Subsurface stormwater infiltration or dispersion component₆ Down-gradient₇: 30ft 10ft N/A Up-gradient₇: 30ft 10ft N/A Other site features that may allow effluent to surface Down-gradient₂: 30ft 5ft N/A Up-gradient₂: 10ft N/A N/A Down-gradient cut or banks with at least 5ft. of original undisturbed soil above a restrictive layer due to a structural or textural change 25ft N/A N/A Down-gradient cuts or banks with less than 5ft. or original, undisturbed soil above a restrictive layer due to a structural or textural change 50ft N/A N/A Soil dispersal components serving a separate OSS 10ft N/A N/A ₁ If surface water is used as a public drinking water supply, the designer shall locate the OSS outside the required source water protection area. ₂ The item is down-gradient when liquid will flow toward it upon encountering a water table or restrictive layer. The item is up-gradient when liquid will flow away from it upon encountering a water table or restrictive layer. ₃ Any in-ground containment vessel used for store drinking water. ₄ A network of underground piping carrying fluid under pressure used to heat and cool a structure. ₅ Lined means any component that has the intended function of detaining the stormwater with no intention of dispersal into surrounding soil. ₆ OSS components take precedence in cases of horizontal setback conflicts between OSS and stormwater components. ₇ Down-gradient means that subsurface water flows towards and is usually located lower in elevation. Up-gradient means subsurface water does not flow toward and generally flat, or flows away and general located higher in elevation. ₈ Unlined means any component that has ability to or intended function of infiltrating the stormwater.