SS-188B
Rev. 12/14
West Virginia Department of Health & Human Resources
_____________________Health Department
SITE EVALUATION for SURFACE DISCHARGE for NEW CONSTRUCTION
Property Owner:
Telephone:
Mailing Address:
Property Location (be specific):
Property Size:
sq. ft. / acres Year lot was created:
Lot must be a legally created lot with respect to subdivision regulations in WV64CSR9
.
Proposed use:
Single Family Dwelling, # Bedrooms ______
Other (describe)
Gallons per day Per Table 64-47-B of the Sewage Design Standards design loading:
gpd or per actual water usage:
Is there an existing septic system on the lot:
Straight pipe to surface discharge
Septic tank with surface discharge
Unpermitted septic tank / soil absorption system
Permitted septic tank / soil absorption system
Other. Describe:
The following site conditions preclude installing a conventional soil absorption system:
Percolation Rate too slow Reported percolation test result:
.
Inadequate room for soil absorption field
Shallow depth to seasonal high water Depth to groundwater table:
High bedrock Depth to bedrock:
feet
inches
Excessive slope
Copy of the denied SS-182 or SS-182A application attached, OR
feet
inches
Percolation tests were not performed because:
On larger lots or farms: Pumping to a suitable installation area for onsite disposal is not being considered because:
Site
does
does not have access to a year round stream.
Proposed discharge point:
Year round stream. Name:
Wet weather stream
Road ditch Culvert crossing roadway
Existing pipe crossing neighbor’s lot
Natural drainageway
Describe:
Recorded easement necessary to cross adjoining property?
Yes
No
Notarized easement attached? ____________________
Comments:
Based on all available information and testing, this is a legally created lot, and a surface discharge sewage system is the only
acceptable option for this property:
Date:
Sanitarian Signature:
Sanitarian must fax this form directly to the WVDEP prior to application being processed—Fax# 304-926-0496