West Virginia Department of Health & Human Resources Department of Health

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1 SS-182A Rev 6/07 West Virginia Department of Health & Human Resources Department of Health Application for a Permit to Install or Modify an Onsite Sewage Disposal System Property Owner Phone (H) (W) Address City State Zip Code Property Location Has this property ever been previously denied for a permit? Yes No Date Facility is New Existing Lot Size Acres /Sq. Ft. Water Source Type Facility Residence Other Number of Bedrooms Number Individuals Served Design Daily Flow gpd Deed Recorded in Deed Book Page County Tax Map Parcel No. Subdivision Name Approval No. Section Lot The minimum lot size or area reserved for a sewage disposal system in a subdivision may vary based on the date the subdivision was created. On lots created after July 1, 1970, permits for individual sewage disposal systems shall be withheld until a subdivision approval has been granted which indicates that such systems may be expected to comply with applicable design standards on all proposed building lots contained within the original tract. To the best of my knowledge, the information provided on this application is true and I understand that I am responsible for informing the sewage system installer of the existing or proposed locations of sewage systems and water sources including wells. I further understand that it is my responsibility to consult the sanitarian for assistance as necessary and to determine the location of any existing or proposed sewage systems or wells if presently unknown to me. Date: Signature of Owner: Sewage Disposal System Information Application is for a permit to: Install Modify Check all that apply: Septic Tank Absorption Field Holding Tank Pit Privy Vault Privy Alternative System (attach detailed plans) Chemical/Composting Toilet Other Percolation Test: Test Holes #1 mins. #2 mins. #3 mins. #4 mins. Total Minutes = Divided by 24= Average time for water to fall one inch. Six-foot hole is free of water or solid rock? Yes No Test conducted on (date) I hereby certify that the percolation test was conducted in accordance with the procedures outlined in the Sewage Treatment and Collection System Design Standards, 64CSR47. Notice: all homeowner installers must pass a certification examination administered by the Local Health Department prior to conducting perc testing. Date: Signature of Certified Installer: For Health Department Use: Coordinates N W Date Rec d Site Eval By Date Fee Pd Rec d From Permit Issued Denied Permit # Comments

2 Septic Tank: Capacity (gallons) Material Top Seam or Mid Seam Manufacturer Outlet Filter Used? Yes No Manufacturer Drain Field: Materials: Gravel Gravelless Pipe Chambers Other Brand 300 ft 2 /BR 400 ft 2 /BR Other No. Bedrooms X ft 2 /BR = total ft 2 No. Lines Length of Lines (ft),,,,,,, Trench Width (ft) Average Depth Max Depth Pipe ASTM No. Effluent distribution (check all that apply): Distribution Box Serial Pump dosed Siphon dosed If Absorption Bed: Length (ft) Width If chambers: # Used Brand Separation Distances (ft) Septic tank to: Bldg Foundation Property Line Water Supply Absorption field to: Bldg Foundation Property Line Water Supply Draw a sketch of the property showing any existing or proposed well locations, the location of all structures, property line locations, and the proposed sewage system as it is to be installed. Show all structures and facilities to be served by on-site sewage on the lot. Design Sketch: Certified Installer Business Address Certification No. Exp. Date Telephone Contractor s License No. Exp. Date Issued to I hereby certify that the installation or modification of all parts of the sewage disposal system, including required material standards, will be done in compliance with the Sewage Treatment and Collection System Design Standards Rule, 64CSR47, and appropriate manufacturer s recommended procedures and practices. Date: Signature of Certified Installer:

West Virginia Department of Health and Human Resources MANUAL OF ENVIRONMENTAL HEALTH PROCEDURES Section Waste Water Date March 28, 1989 Procedure # WW-4 Subject Sewage Holding Tanks Page 1 of 1 This

3 West Virginia Department of Health and Human Resources MANUAL OF ENVIRONMENTAL HEALTH PROCEDURES Section Waste Water Date March 28, 1989 Procedure # WW-4 Subject Sewage Holding Tanks Page 1 of 1 This office developed a policy providing guidance for the use of holding tanks in Review by the Department has indicated limited success due to the high price of pumping; the few sewage haulers that have the capability to provide long-term, uninterrupted service; and problems associated with the availability of sewage treatment plants and land disposal sites that will accept septage. These problems have caused holding tanks to be neglected resulting in overflows and public health concerns. For these reasons the Department has revised the policy as follows: Sewage holding tanks can only be approved for new construction after a contract for the development of a public or private sewage collection system and/or treatment facility to serve the proposed new construction has been awarded. County health departments may approve individual homeowner requests for a period not to exceed six months. Requests from commercial and industrial facilities and individual homeowners for periods in excess of six months must be approved by the Director, Office of Environmental Health Services. In all cases, the holding tanks shall be constructed in accordance with current regulations and design standards. In considering a holding tank application, the attached Holding Tank Approval Criteria should be reviewed and followed. References History Replaces WW-4 dated September 2, 1982 Attachments Holding Tank Approval Criteria

4 West Virginia Department of Health & Human Resources Office of Environmental Health Services HOLDING TANK APPROVAL CRITERIA 1. A holding tank must be water tight and constructed of the same materials and in the same manner as a water tight septic tank. With the exception of the cleaning pumping port, no openings or pipes through which the contents of the tank may be discharged will be permitted. 2. The liquid capacity of the holding tank shall be sufficient to contain at least one week s design flow from the facility to be served. Flow is to be calculated as per Sewage Treatment and Collection System Design Standard, 64 CSR A holding tank installation shall be provided with an audio-visual high level alarm when the tank is approximately two-thirds full and will require pumping shortly. The alarm is to be located inside the facility served. 4. Holding tanks shall be located in accordance with the distance requirements established in Individual and On-site Sewage System Design Standards, ES Holding tanks shall be located in an area readily accessible for pumping under all weather conditions and where accidental spillage during pumping provides the least hazard to public health. 6. Construction and installation of the holding tank shall provide adequate access to the tank for pumping, cleaning and maintenance through a manhole port or cleanouts. 7. A contract with a licensed sewage tank cleaner with a valid permit for pumping and maintenance of the tank on a regular schedule shall be required. 8. A letter from a wastewater treatment plant owner accepting the pumpings shall be required. This facility must meet the approval of the Director. 9. When it is deemed necessary to protect the public health, the Director reserves the right to require additional assurances before approving holding tanks. 10. A complete application (Form SS-182A) with layout and specifications must be submitted with applicable fee. Include check for $1, made payable to: WV Bureau for Public Health. Note: Cost to pump a holding tank for a single family dwelling even with water conservation can exceed $ per month. 100 gallons per day X 30 days X $150.00/1,000 gallons pumped Mail completed application to: Office of Environmental Health Services 350 Capital Street, Room 313 Charleston, WV

5 64 CSR 51 Appendix B. Environmental Health Services Fees. 1. Water Systems, Sewage Systems and Swimming Pools A. Construction/Installation Permits Public Water System Project $ Public Sewer System or Facility Project $ Public Swimming Pool Project $ Sewage Holding Tank Project $1, On Site Innovative/Alternative Type Sewage System Correcting Failure $ New Construction $ Sewage System Installer Certification and Renewal $ B. Water Well Permits (New Construction) $ Public Water System 2. Bottled Drinking Water/Water Vending Machine Permits A. Distributors, Annually $ B. Producers and Distributors, Annually C. Facility Size (measured in Gross Sales) 1. $0.00 to $24, $ $25, to $49, $ $50, to $99, $ $100, to $499, $ $500, to $999, $ $1,000, to 4,999, $ $5,000, to 9,999, $ $10,000, to 24,999, $ $25,000, to 49,999, $ Greater than $50,000, $1, D. Vending Machines, Annually $ Plus per machine Radiological Registration 14

6 Information to accompany application (SS-182A) for permit to install a Holding Tank: 1) Name of the proposed facility or business Mailing Address Location name 2) Name of facility contact person: address Telephone - - 3) Physical location & detailed directions, including Latitude/Longitude coordinates. County(WV) N Lat W Lon 4) Pre-existing structures on property prior to this application: Date constructed or installed 5) New structures planned to be built or placed on property 6) Type of operations to be conducted at the facility 7) Number of persons employed or residing at the site Estimated total gallons water use per day = [NOTE: There must be a total of seven days retention capacity provided by proposed holding tanks.] 8) Proposed Holding Tank(s) sizes: Tank #1 Tank#2 #3 #4 9) Tank Manufacturer Model 10) Size of lot? acres Current use of the property? 11) Distance from the facility to the closest PSD s or municipalities existing sewage collection lines? 12) Has an application for permit for an onsite system been denied? date of denial 13) Reasons why an onsite system is not feasible? 14) Name of licensed septic tank cleaner that will service tanks? 15) Letter of acceptance from the sewage handling facility where waste will be disposed, attached? 16) Details of high level alarm (design, make, model), attached? Also, please submit a plat or tax map of the property, with sketch the facility to be served, and showing the holding tank location(s), water supply source and piping locations.

Contact Information Owner s Name Home Phone Cell Phone Mailing Address City Zip Code

Contact Information Owner s Name Home Phone Cell Phone Mailing Address City Zip Code Henry & Stark County Health Department Environmental Health 4424 US Hwy 34, Kewanee, IL 61443 309-852-0197--309-852-3115 www.henrystarkhealth.com Henry County Stark County Received by: Amount Received: