provides a list of licensed on-site sewage designers.

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1 GRAYS HARBOR COUNTY DEPARTMENT OF PUBLIC SERVICES ENVIRONMENTAL HEALTH DIVISION 100 W Broadway Suite 31 Montesano, WA fax Fees: Alternative Sewage Disposal Permit (Pressure/Advanced Systems)....$740 Conventional Gravity Sewage Disposal Permit....$640 Commercial Sewage Disposal Permit....$900 Repair Permit... 50% of Above Base Fees Tank Placement... $315 Re-Inspection... $95 Additional Revision... $130 Existing System Evaluation... $125 (This fee is applied toward permit fee if system requires changes) Extensions... $170/YR Winter Observations... $380 1) Complete all information pertinent to your proposal. CHECK WITH THE APPROPRIATE ZONING AGENCY. Use N/A for lines that do not pertain to your proposal. Your correct parcel number must be on the application. If located in a subdivision, indicate the plat name, lot, block, and/or division number. Give directions to the site and attach a map if necessary. 2) Water Supply: If the proposed water system is un-approvable by the Environmental Health Division, permits cannot be issued. Individual water supply: a water supply, which will serve no more than two single-family residences. Public water supply: a water supply, which serves anything other than a single-family residence. If your water falls in the public water system category be sure to include the name of the public water system. Wells on lots created after January 1, 1995, need to be 100 feet inside property lines or have restrictive covenants on adjacent lots. 3) For all permits excluding new/expanded sewage disposal permits a detailed plot plan must be drawn on the attached site plan provided. Please check off the boxes to the left of the numbers as you add them to the site plan. Indicate all existing structures around existing sewage systems. 4) For all existing system evaluations or repairs, the septic tank will need to be exposed so an inspection can be made of sanitation tees or baffles (both inlet and outlet). 2 test holes will be required for septic system repairs. Call before you dig requirements: When digging greater that 12-inches call to avoid running into underground utilities. 5) For new/expanded systems, septic design must be submitted with application; before inspection can be made at least two (2) soil log holes are required in the proposed drainfield area. The holes must be 50 feet apart and dug according to the diagram located on the back of this page. Shallower holes will be assumed to have encountered a restrictive layer (hardpan or a water table). If soils appear clay-like, very wet or hard, it is suggested that additional holes be dug before inspection. Existing system evaluations may require soil log holes. 6) If the existing residence is to be replaced and/or additions are planned for the existing dwelling, indicate on the application the total number of bedrooms when construction is complete. Please stake location of proposed residence and/or addition on property. 7) Place your name on a sign and post it in front of the site. Also flag test holes (stick with ribbon attached) so as to be visible from the road. If flags are not visible from the road, run strings from the sign to the test holes. 8) To avoid possible liability to yourself, the soil log holes should be filled as soon as possible after the inspection. 9) Any proposed development requires that the on-site sewage disposal system be designed by a licensed professional engineer or designer. The following websites, provides a list of licensed on-site sewage designers. The site will be evaluated as soon as possible. The amount of time to process your application will vary with the workload of this office. You will be notified by mail of the results after completion. Your patience is appreciated. Please return this statement with the application, site plan and necessary fees. PLEASE CHECK ONE BOX BELOW: SITE IS PROPERLY PREPARED: I WILL CALL WHEN READY: By the presence of my signature I affirm that I have read and understand all of the above: Date

2 GRAYS HARBOR COUNTY DEPARTMENT OF PUBLIC SERVICES ENVIRONMENTAL HEALTH DIVISION 100 W Broadway Suite 31 Montesano, WA fax RECEIPT ON-SITE SEWAGE APPLICATION NEW SYSTEM REPAIRED SYSTEM EXPANDED SYSTEM EXISTING SYSTEM TANK PLACEMENT *REQUIRED FIELDS *Site Address *Applicant s Name *Signature *Applicant s Mailing Address *City *State *Zip *Phone (home) (mobile) *Owner s Name & Address Township Range Section *Parcel # Subdivision Name Div. Lot Block *Directions to Site *Description of proposal *Property Size *Total # of Bedrooms *Basement Plumbing: YES NO *Type of Building: Single Family Multi-Family Food Establishment Commercial *Water Supply: Individual 2 Party Public Name of Water Supply For Existing Systems: Number of Existing Bedrooms Proposed Additional Bedrooms Call before you dig requirements: When digging greater that 12-inches call to avoid running into underground utilities. ************************************************************************************************************************************* FOR ENVIRONMENTAL HEALTH USE ONLY Soil Type Application Rate Existing Permit # Depth of Water Table or Indicators Absorption Area Sq.Ft. Date Record of Action By Drainfield Total Length Feet Trench Depth Inches Trench Width Inches Septic Tank Gallons Pump Required Comments: Date System Designer System Installer Design Final Approved By Approval By Hold Reason By Disapproved Reason By THIS PERMIT EXPIRES Permit #

3 Department of Public Services Phone: Fax: West Broadway; Suite 31 Montesano, Washington Site Plan Instruction Sheet GRAYS HARBOR COUNTY STATE OF WASHINGTON **PRE-DEVELOPMENT REVIEW APPLICATION SITE PLAN MAY BE USED FOR SEPTIC SITE PLAN The processing and issuance of your on-site sewage, building, or land-use permit is often delayed because the site plan submitted is incomplete and illegible. Hence, it is required that the application for such permits be accompanied by an accurate and complete site plan. A complete site plan must include the following: 1. The North arrow and the scale you are using. 2. All property lines, giving the dimensions. 3. Driveway location from county or state access to the proposed structure. Include all paved/concrete surfaces such as patios, in addition to driveways. 4. Major features of the property (ravines, seasonal and year-round creeks, and bodies of water such as lakes, ponds, bays, oceans). 5. Location of on-site sewage system including the tank and drainfield, and its distance to structures and property lines. 6. Location of wells or drinking water source, and its distance to on-site septic system, structures, and property lines. 7. Location of all existing and proposed structures and their distance to property lines. 8. Location of the plumbing stub-out of the proposed structure. 9. Location of all wells or drinking water sources within 100 feet of the property line. 10. Signature and date on the site plan. Provide us with a copy, keeping the original with your permanent records. We also urge you to keep copies of all permits, inspection records, and any supporting documents, such as easements, surveys, and legal descriptions to name but a few. WARNING: Grading a particular area may render that site unsuitable for an on-site septic system. If the proposed fill area is in the area of an existing or planned on-site septic system, we urge you to contact an Environmental Health Specialist to discuss it before proceeding.

4 Sample of acceptable σite plan. SCALE: 1 = 20 STREAM WET AREA N IDENTIFY EASEMENTS 7 UTILITY EASEMENT 100 FT MIN. WELL 100 FT MIN. 100 FT MIN. SETBACK FROM SURFACE WATER PROPERTY LINE & DIMENSIONS σ--test HOLE # 3 σ--test HOLE # 1 REAR YARD SETBACK DRAINFIELD P/L 250 FT. σ--test HOLE # 2 10 MIN. SEPTIC TANK NEW ADDITION 5 MIN. 8 CONCRETE PATIO 55 SIDE YARD SETBACK 24 EXISTING HOUSE SIDE YARD SETBACK ROOF OVERHANG 2 FOOT MAX IF WITHIN REQUIRED SETBACK P/L 100 FT. 21 DRIVEWAY FRONT YARD SETBACK PROPERTY LINE-TO-BUILDING SETBACKS ARE DETERMINED BY ZONING DISTRICT OPEN DRAINAGE DITCH FIRST AVENUE CULVERT SAMPLE SITE PLAN 06/15/07

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6 Guidelines for Test Pit Construction for On site Sewage Systems Safety and soil characterization are both important when constructing a test pit for an on site sewage system soil review. The three test pit options in this guidance will meet the Washington State Labor and Industries (L&I) safety requirements in Chapter WAC. The three options can be used for all soil types listed in On Site Sewage Systems Chapter A WAC and Chapter B WAC except as noted below. Local Health Jurisdictions may have more specific guidance for their local area. The reviewing agency should be consulted before test pits are constructed. Test Pit Construction Call 811 to locate underground utilities prior to digging. All test pits must be evaluated for stability by a competent person per WAC Test pits shall not be entered if deemed unstable. Use the least stable soil for evaluating test pit stability when there is a layered soil profile. Regardless of soil type, a test pit that shows distress such as fissures or cracks is deemed unstable. Benching for test pit stability can only be done in unsaturated soils with greater than 15% fines (silt and clay). This means some DOH Type 1, Type 2, and Type 3 soils and soils seeping freely may not qualify for Test Pit Option A. The three test pit options do not allow an evaluator to enter the test pit to a depth greater than 4 feet. To enter to a depth greater than 4 feet, additional requirements in WAC must be followed. Every test pit must have a ramp that provides for entry and exit into the test pit without the need of aid. All spoils must be placed at least 2 feet from the edge of the test pit. All equipment within 20 feet of the test pit should be shut down when a person is in the test pit. For Large On site Sewage Systems (LOSS) an excavator must be on site. Test pits shall not be left open for an extended period unless properly barricaded per L&I regulation. An example of a properly barricaded test pit is orange construction fencing surrounding the entire test pit and secured by metal fence posts. For more information contact Washington State Department of Labor and Industries, your local health jurisdiction, or the Washington State Department of Health. DOH July 2012