site risk surveyfor large on-site sewage systems（网站surveyfor大型现场污水系统风险）.docVIP

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site risk surveyfor large on-site sewage systems（网站surveyfor大型现场污水系统风险）.doc

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The Washington State Department of Health (DOH) requires a Site Risk Survey (SRS) for all new Large On-Site Sewage Systems (LOSS). DOH may also require an SRS for existing LOSS. Information provided in the SRS may identify potential health and environmental impacts resulting from the LOSS. If so, DOH may require further information such as a Hydrogeology Report. You may choose to submit a Hydrogeology Report instead of the SRS. If so, please discuss that option with LOSS staff beforehand. You may disregard this form, although this information should be included in the Hydrogeology Report. Completing this Form Before you begin filling in the form, be sure and save it to your hard drive. Your data will be lost if you close the form without saving it to your hard drive. The SRS may be sent electronically or filled out by hand and submitted as a hard copy. If you send the SRS electronically, save the file and send as a PDF copy. All SRS must be signed and dated. An electronic signature is acceptable on a PDF copy. Please provide references for the information you use to complete the SRS. References can be attached to your electronic submittal, mailed hard copy, or provided as an on-line link. If you send the SRS electronically, maps and other supporting data can be attached. All attachments must be legible at a printable size of 11” x 17” or smaller. Please send a hard copy if the attachments cannot be read at this size. Answer all questions on the SRS. If the question is not applicable to your site, write N/A. Use the comment sections in the SRS to provide additional information. If completing the form on the computer, use your tab key to move forward to the next box or use shift/tab to reverse. Save your file. If sending electronically, email to Nancy.Darling@. If sending by FAX, send to 360-236-2257. If mailing, print the completed form and make a copy for your records. Mail the original to : Nancy Darling Washington State Department of Health Office o