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COMMONWEALTH of VIIRGI[NIA
In Cooperation with the Thomas Jefferson Health District ALBEMARLE-CHARLOTTESVILLE
State Department of Health FLUVANNA COUNTY(PALMYRA)
1138 Rose Hill Drive GREENE COUNTY(STANARDSVILLE)
LOUISA COUNTY(LOUISA)
Phone(434)972-6219 P. O. Box 7546 NELSON COUNTY(LOVINGTON)
Fax (434)972-4310
Charlottesville,Virginia 22906
September 13,2018
Tori Kanellopoulos
County rle app CI, D'
Department
of of Community Development
401 McIntire Road
Charlottesville,Virginia 22902-4596
RE: Review of Proposed Subdivision Plat and attached Soils Information for Individual Onsite
Sewage Systems as part of a division of Tax Map 22 Parcel 3D located in Albemarle
County,Virginia.
Dear Tori Kanellopoulos:
On August 30,2018,the County of Albemarle requested the Virginia Department of Health(via the Albemarle
County Health Department)review the proposed subdivision plat identified above.This letter is to inform you
that the above referenced subdivision plat is approved for individual Onsite Sewage Systems in
accordance with the provisions of the Code of Virginia,the Sewage Handling and Disposal Regulations,
and local ordinances.
This request for subdivision review was submitted pursuant to the provisions of§32.1-163.5 of the Code of
Virginia which requires the Health Department to accept private soil evaluations and designs from an
Authorized Onsite Soil Evaluator(AOSE)or a Professional Engineer working in consultation with an AOSE for
residential development. This subdivision was certified as being in compliance with the Board of Health's
Regulations by: Jason Kyser OSE#1940001357. This subdivision approval is issued in reliance upon
that certification.
Pursuant to §360 of the Regulations this approval is not an assurance that Sewage Disposal System
Construction Permits will be issued for any lot in the subdivision identified above unless that lot is specifically
identified on the above referenced plat as having an approved site for an onsite sewage disposal system,and
unless all conditions and circumstances are present at the time of application for a permit as are present at the
time of this approval. This subdivision may contain lots that to do not have approved sites for onsite sewage
systems.
This subdivision approval does pertain to the requirements of local ordinances.
Sincerely,
Travis T.Davis,OSE
Environmental Health Specialist,Sr.
Page / of IV
OSE/PE Report for:
Construction Permit n Certification Letter Subdivision Approval I
Property Location: I
911 Address: 3.57/ �ur n �S'fp�i On Root'oot' i CitY: �MrJo ucs v�1�L
Lot D Section Subdivision kiiiAnr� Atwid l
GPIN or Tax Map# ZZ pI rc•l 3p Health Dept ID#
Latitude Longitude
Applicant or Client Mailing Address: 1511 EPPROVED
Name:
Street: _Heirs3$9/ ite e„�s� o 'R p�
City: �pr�v rsv;!Ie Y State t/9 Zip Code_ Z29132.-
Prepared by:
OSE Name f;v nq .Sys( Ca„s,1141 at ysy-L y9-Pee License# /7Voo0/35 7
Address Z O, Box 75S
City KeswP k State (IF? Zip Code Z-Z9y7
PE Name: License#
Address
City State Zip Code
Date of Report OSIZyl201$ Date of Revision#1
OSE/PE Job# Date of Revision#2
Contents/Index of this report(e.g.,Site Evaluation Summary,Soil Profile Descriptions,Site Sketch,Abbreviated Design,etc.)
far 1-2 03E ties. ; 5 p Ap 13 stc..+ `.'pst$.l�ile.
DpI-6 3-if &,s}Pna bF =to �i►f ( 5.,1
pin/et-' °-10 53.c J�.,,,r..,,�.y ; r
par tl- 12 146t'M GtIcS ;
Certification Statement
I hereby certify that the evaluations and/or designs contained herein were conducted in accordance with the Sewage Handling and
Disposal Regulations(12 VAC5-610),the Private Well Regulations(12 VAC5-630)and all other applicable laws,regulations and
policies implemented by the Virginia Department of Health. I further certify that I currently possess any professional license required
by the laws and regulations of the Commonwealth that have been duly issued by the applicable agency charged with licensure to
perform the work contained herein.
El""" .......le work attached to this cover page has been conducted under an exemption to the practice of engineering,specifically the
exemption in Code of Virginia Section 54.1-402.A.11
I recommend that a(select one): construction permits certification letter subdivision approval
be(select one)issued denied❑.
OSE/PE Signature Date P.CAcf t 8
--"— 13e 2 of /y
Commonweal h of Virginia VDH Use only
Health Department ID#
Application for: IPSwage System []Water Supply Due Date
Owner 11-e,:ors ot Finley d. �n�l t 1 Phone 939-,QL-7/4 7
Mailing Address 3S9 I B�.r/n I..1 Sl., kor, /Qod d Phone
3164ebou.,r3villc 1/11 22923 Fax
Agent <scs el 1";‘,41,1 6. /Q,4�(nr.1 Phone 931/-704- 747
Mailing Address 3591 8',.(4 ) 5)141-1on 4ei Phone
gp✓ 0,4-sv;11{. (/A Z29Z3 pp Fax
Site Address 359/ 8G c.l lay SM�'ori ICL.Ii
✓Joarsv�//< 1�19 22723 Email
Directions to Property: Jrm�,.��►S:as o L t,4'J
Subdivision Rr}J�Nr�a Jay. fir_ Section Block Lot p
Tax Map Z.Z. orhrc,ef 3D other Property Identification Dimension/Acreage of Property Z.eV 41e4,e,,
4 / Sewage System
Type of Approval:Applicants for new construction are advised to apply for a certification letter to determine if land is
suitable for a sewage system and to apply for a construction permit_(valid for 18 months)only when ready to build.
Certification Letter ':I-Construction Permit f'Voluntary Upgrade 'Repair Permit rEKAihkoven 41iev
Proposed Use:
Single Family Home(Number of Bedrooms 3 ) Multi-Family Dwelling(Total Number of Bedrooms )
Other(describe) , �
Basement? Yes ,,,lVo Walk-out Basement Yes Fixtures in-BasementDYes9bto
Conditional permit desired?®Yes o If yes,which conditions do you want?
❑Reduced water flow ❑Limited Occupancy 0 Intermittent or season I use ❑Temporary use not to exceed 1 year
Do you wish to apply for a betterment loan eligibility letterf_ss o *There is a$50 fee for determination of eligibility.
j Water Supply
Will the water supply_ ea thlic_ te? Is the water suppl cisti tg �ed2
If proposed,is this a replacement well?DYes ONo If yes,will the old well be abandoned?[ Yes DNo
Will any buildings within 50'of the proposed well be termite treated?( Yes tO
All Applicants
Is this a private sector OSE/PE application?_ es-]No If yes,is the OSE/PE p kage attached? No
Is this property indeed to serve as your(owners)principal place of residence? � No___
In order for VDH to process your application for a sewage system you must attached a plat:of the property and a site sketch. For water
supplies,a plat of the property is recommended and a site sketch is required. The site sketch should show your property lines,actual and/or
proposed buildings and the desired location of your well and/or sewage system. When the site evaluation is conducted the property lines,
building location and the proposed well and sewage sites must be dearly marked and-the property sufficiently visible to-see the topography.
I give permission to the Virginia Department of Health to enter onto the property described during normal business hours for the purpose of
processing this application and to perform quality assurance checks of evaluations and designs certified by a private sector Onsite Soil
Evaluator or Professional Engineer as necessary until the sewage disposal system and/or private water supply has been constructed and
approved.
Signature of Owner/Agent Date
This form contains personal information subject to disclosure under the Freedom of Information Act. Revised 12/1/2014
MINI 1.11
,i • ' � - ..•• .
!Application• for a' Sewage-- Disposal, System Construction Permit
se
Health Department ? •1 ® • ig
Commonwealth of Virginia For Department Use Only P •, .Z�� .,.
Department of Health Identification Number
" • Map Reference' �.. .!"3L• •
<'n, ��;�;� ��y-� r ••' Date'Received S �0i/' : . " ;
7t/ Health Department .�-
To Be Completed By The Applicant '
r, Type sewage'system: , New , . p: Repair, ❑ Expanded ❑ Conditional-
. FHA/VA yes ❑.. ,no-'( '.: • •
1 d
Owner '_/\/[Y -F'"A Q•1 �G G Address A" l / 1 fa(o Phone 73_37 4�.
�. ),,.gnu- \A I Yam_ 22 23 -
+ Oc. C. E 1 �.., .-.5� Phone 2.9:1)-.574�
Agent �l-�J-P Address; 2 rt
- i -� '�'t t,ti o r, -o . �n 4-i 9 Z•m e o y
Directions ,to Propert •
y - 29 l,_ -o "Cfl4- J ' 1 vl P�
Section . Block. iLot
Subdivision" '8J r Sq5 ^ t
• Other Property Identification a� � "(7 2 2 - O 3 .
Dimensions/size_of Lot/Property. z 2 A.Cti e-5 I
Other Application Information
I. Building/facility : , ,-❑ New J� •N�
xisting •
Intermittent Use ❑ Yes . o if yes, describe:. •
II. Residential Use ,> Yes ❑ No i
Termite,Treatment ❑ Yes Y . ,Mr. • f �l
. ,gi'SingleFamily' -_ ❑ Multifamily Number of Units — Number of Bedrooms.
:, Basement ❑ Yes•. No
`Fixtures in Basement 0Yes" No
III. Commercial,.Use ❑ Yes ;. •• • , o Describe: •
•
Commercial/Wastewater ❑ Yes . i Number of Patrons _____ Number of Employees .
if yes, give volumes and describe •
Public CI Describe: t- ,� t v'� Ati`\ t e e�k
IV. Water Supply: ❑ r
• 1 rivate ❑ Existing ;
V.. Proposed Installation: . , Septic tank and drainfield ❑ Other; '
if other, describe •
SITE Attach a site plan (rough sketch) showing dimensions of property, proposed and/or existing structures and
PLAN . 'driveways, underground utilities, adjacent soil,absorption systems, bodies of water, drainage ways, and wells
-, and-springs within 200 feet radius of the center of the proposed_building or drainfield. Distances may be paced
or estimated.' •
•The property- lines,':ar d building location are clearly marked and the property is sufficiently visible to see the to-
' 'pography. I give permission to the Department to enter onto the •property described for the purpose of processing -
this application. :0— , 2.___: .2V(' y 19&�
.S:200 e ( 1 (...__.,9nalt..- igloo 1e S gent CO
(,,, Vf--.4- 7 fC•H.S:200 Revlsed 4/83 ..�I} '• /r- 1 ti �•1� Wh K!-J .1 'J
. ri
.. PAGE I OF z-
,
Soil Evaluation Form l
Commonwealth of Virginia Health Department S�_ ys-Z2a
Identification Number 2-2Z
Department of Health Tax Map Number
General Information
Health Department
Date 1 �5
Applicant
1N t n Telephone No. 293-6 74Y
C \lcc. 22923
Address(�'-' (( {{' (/�,,�� ;] n�
owner rtr1, IarY't Address � I ^ "� /ti Dat�UCx)i•3YiAC 1VG.
-th 8V,--) 01 12i. (o 4 I a bo31 2 m ll.<.a •t�f6g-9" e R1 . 2,9 t''�
� Location Subdivision pp�� ,/�
Ain- Block/Section 1vir Lot Jtr
.�1
I
Soil Information Summary
1. Position in landscape satisfactory Yes lgr No 0 Describe
2. Slope - 4- % • ,
3. Depth to rock/impervious strata Max. Min.
None i/
ra mottlingor graycolor) No Yes 0 . inches
4. Depth to seasonal water table�(9 y
5. Free water present No
Yes ❑ • range in inches -
�
6. Soil percolation rate estimated YeNo
0 Estimatedmure group I II IV
rate .b min/ inch • \\\
7. Percolation test performed Yes ❑ Number of percolation test holes fi ;
No Depth of percolation test holes
Average percolation Nate -__ _
} ,w .. SanIfarutn _
. • Name and title riTlueye o :
Signature:
• Department Use
�- Site Approved: Drainfield to be placed at `= depth at site designated on permit. ..
❑ Site Disapproved: .
Reasons for rejection:
1. 0 Position in landscape subject to flooding or periodic saturation.
2. 0 Insufficient depth of suitable soil over hard rock.
3. ❑ Insufficient depth of suitable soil to seasonal water table.
4. 0 Rates of absorption too slow.
• 5. ❑ Insufficient area of acceptable soil for required drainfield,and/or Reserve Area.
6. ❑ Proposed system too close to well.
7. ❑• Other Specify
C.H.0.201A Portwd 4/53 - -
• /" r, 4
Profile Descrlptian Health Department _ �,`«
Date of Evaluation g5 SOIL EVALUATION REPORT . Identification No. " j� �__�
Page_ 9• 2 • of Z -
Where the local it oh dep ht ubmitt conducts d the soli
theep if n the Isoii e n of a ua ionsprofile
areholes
conduct by a private the
soilschematic
sc scientist, location of pro-
file
and
or th sketchreasubmitted withn application. andetc.,attached to fe form.
•
holese and anddhr of eserve site shall be shown ondthe reverse sideiofethis page ore prepared disposal'
pageseparate' is, within 100 thisst of site
(See Section 4) .
See construction permit 0 See sketch on reverse side or . . .
ID See.application sketch 0 page attached to this form.
•
• Descri tion of, color,text re,etc. - - -- Texture Group,
Hole# i Horizon Depth (inches) �t�Q •
T -
Z vii O^ie ' A r'
IIIII
. IIIIMIIIIIII I 41 f,. il..\1,-.,: ot.0 _ ' cuf, . 011.(Y\ .',.:',' ''..., ''.: ..7.. i i .
711 • • 4.
11111_ I . t
En i
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______________________ _______________ .
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Remnarks•
I
t -y � ,
CH.B Z018 Revised 4/tr3
gm
Health Department r 5_ Z 0x .. Identification Number 15 r'
4 • P� E 2- OF Z
Schematic drawing of sewage disposal system and topographic features.
Show the lot lines of the building lot and building site, sketch of property showing any topographic features which may impact on the design of
theisystem, all existing and/or proposed structures including sewage disposal systems and wells within 100 feet of sewage disposal system and
reserve area. The schematic drawing of the sewage disposal system shall show sewer lines, pretreatment unit, pump station, conveyance sys-
tem and subsurface soil absorption system, reserve area, etc. When a nonpublic drinking.water supply is to be located on the same lot show all
• sources of pollution within 100 feet.
-0 The information required above has been drawn on the attached copy of the sketch submitted with the application.
Attach additional sheets.as necessary to illustrate the design. 4 j>l4r,
3 Lot 0c'
42.`.
r \Otl�r,;‘ �1 ..
� � � ) '®� to
II1i a.
lam.-------•toy ;
j'‘(',* Mt . • !.1..1 "17'8 ' '''•-: -: ' ' •) • .`.,
• / - / '
The sewage disposal system is to be constructed as specified by the permit D. or attached plans and specifications O .
.This sewage disposal system constriction permit is null and void if (a) conditions are changed from those shown on the application (b) condi-
tions are changed from those f'iown_on the construction permit.
No part of any installation shall be covered or used until inspected, corrections made if necessary, and approved, by the local health department
'~ or unless expressly authorized by the local health dept. Any part of any_1stallation 'which has been covered prior to•approval shall be uncov-
ered,if necessary,upon the direction of the Department.• _ •
( ç1i This Construction
Date:. Issued by: ` t�
_ \I((//�� Sanitarian Permit
f Valid`' until
t ✓ 1 ( n X A AM , !1 f G 1/d ;�
�. !� `� Reviewed by: r
Date: �' ij Supervisory Sanitarian
' If FHA or VA financing
Date
Reviewed by Date Supervisory Sanitarian Regional Sanitarian
•
C.M.S.2028 Devised caw
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PAGE 1 OF____22-• .
S'ew'age: Disposal System Construction Permit -,..- •-• .. _ 1.-
• r.4 ,jilitiffLimiNLI i. . , :
Commonwealth of Virginia •-. /,!' - -- • . Health Department . •
Departmentof Health- . ' . .. Identification. Number SO- 5•5 - 2 20
Health •Department • Map Reference 2.2
• General Information ' • I
Nevi O' Repair 0 Expanded 0 Conditional 0 FHA..0 VA 0 Case No. ,
•. Based' on the application,for a sewage. disposal.system construction' permits filed in.accordance with Section
3.13.01, a construction-permit is hereby issued to: • . . .
Owner, • • ,...sleA 1, VrIn 10 Or•It ' - - • •- • s••" / ' • Telephone
• Address • - j-,-/-t 1 • Pi-4-1 lt-4, .13,4 bi. '"-‘4 ill' VO- -
.Fora Type 7T • Sewage disposal system whic-h is to be: constructed ontat *I-
', .: A t • le; O. 1 (11-1
_
.. . Subdivision A/P- Section/Block /tie Lot MA
.Actual or estimated water use /I,-•-;0 ci-,-r-A-.
.... .
, - ' DESIGN - NOTE: INSPECTION RESULTS
.. -
•
-•- Water supplyieXiilingdidesc,ribe) - - Water supply location: Satisfactory yes 0 no 0 '
•
' "-- -.--,1.--- ' C 1r,-, . comments
-To be installed: class • • r-Y) " •-•.' ' .
G.W.2 Received:•• yes 0 no 0 not applicable E
cased ___f_l_t_146, .. ' • grouted .L ___LfiA. Ain-
.: .Building sewer:• , • .• . - , • . , Building sewer: yes p/no'*D comments
A.' - .—--I.D.'PVC'40-,-or:equivalent: '',,- - SatisfactorY -_.„.._____________ ___• ,
Slope 1. 5" Per-10'(minimum).. • .. -.-
' ' D• Other ;•
. . ..„,. • • ...,
' • Septic tanI6CapacitI Y-;- AO(4 - -gals,-(minimuni),-Pretreatment-unit: :•- yes. Ey•no-.0 comments _
0 Other - • . ' •V SatisfactOry
, ..
-• Inlet-outlet structure.: Inlet-outlet structure: yes EY no 0 'comments
PVC 40,4" tees or equivalent. Satisfactory _ - .
El other ''.
• Pump and pump station: • :..,' .. Pump&pump station: yes 0 no 0 comments
No sp.,' Yes 0 :,desdritie and shown design. . Satisfactory
if yes. AM - , k •
. .. . .
-- : Gravity mains:'Af.'9r larger A.D., -minimum .6" fall per Conveyance method: yes Of no- CI] comments
100' 1500 lb crush strength or equivalent . ." ' ..• :Satisfactoni, .-
.-. . 0 Other _ ,• .• •
.• -
; . Distribution box: 7 , - •
• = . . Distribution box.,. . ,yes /no 0 comments
i0
• "
• . Precast concrete with # .....ports.. • : - Satisfactory - ..,• . •
• 0. Other .• ,.. • . . •' -
,
Header lines: - ' •- Header lines: - yes 0/no 0• comments
Material: 4" I.D. 1500 lb. crush strength plastic or equiva-• Satisfactory • . ,.. : • - • •
.
lent from distribution box_ to 2' into absorption trench.
Slope 2" minimum. . . ' . . . ,
0 Other • . - • . . .
- '• Pereolation lines: . .
" .- • - ' .. I-. Percolation lines: . .yes E/no. 0 comments
• GravitY 4" plastic 1000 lb. Penfoot bearing, load or Satisfactory • ' - - • . •
. . equivalent; slope. 2" 4" (min. max.) per 100'. ' . • • - .• ' '•• •
: .0 Other • V . •• .. •
• .. - . . • ..• , . '
. . /
Absorption trenchee:. . .i.,- -• . %. .. •• .'• ;• .• Absorption trenches:•. -; -.. yes•'0/...no [3- comments
Square ft.required -•1:7b0 :;.depth from ground surface „Satisfactory • . ' : • . :'' - - - .. . - '
to bottom of trench • it 7" ;aggregate size y, - 1 I/7.. ; - •-,.
.
..
Trench bottorhslope ,• -- ) -t:/ /. i ENA .4. - • -- • .
' center to center,spacing __ -;trench width 'R • I. * ' . .• - ,
Date '.71 /7 ia,-:•--/ ' Inspected---and-approved.by:
Depth of aggregate' ," - ; ; •-• • -: /..""7 79 /4--1• Ji •\/24,-
• -Trench length • kW' ;Nurnber of trenches ti. .. . . ,
• SI . "' ""reariTtZT.'-'n -
•
i,.' C.H.S.202A Revised 6184 - 11-2" . le
for /y
VDH Use Only
Health Department 1Dtl
lM17I1'l'
Due Date
Site and Soil Evaluation Report
(For certification letters and subdivisions)
General Information
Date : QS/2y/2o�8 IL/ mods County Health Department
Applicant: HGifS o1 fih1iy G. /Q,9 1A4
Telephone Number: I VJ
Address : 3s?, AA(ftky sbfkory iedoi dA Z273z
Owner: 11-eir5 et A-4,1,1 6. IQA /0,4a Address: 3$,/Du!n lei -5Ji*ov) gqd
Location : �ou.1-ksj< el
a 6111
Subdivision R 4A,Al /Rini)y Block/Section Lot ,D
Soil Informs • n Summary
1. Position in landscape satisfactory Yes No Describe: d
eshr
2. Slope
3. Depth to rock/impervious strata Max./4 Min. 74 None
4. Free water present No tXes Range in inches
5. Depth to seasonal water table(gray mottling or gray color) NM _inches
6. Soil percolation rate estimated Yes 4.7.Texture group Ell 011 RC{ITIV
No Estimated rate SY min/in
7. Percolation test performed Yes ,,tslumber of percolation test holes
No %/' Depth of percolation test holes
Average percolation rate mpi
Name and title of evaluator:
De I tment Use
_✓3ite approved: Drainfield -ench bottoms t• :e placed at 78 (inches)depth at site designated on permit.
Site disapproved:
Reasons for rejection: (check all that app
I. Position in landscape subject to flooding or periodic saturation.
2. Insufficient depth of suitable soil over hard rock.
3. Insufficient depth of suitable soil to seasonal water table.
4. Rates of absorption too slow.
5. Insufficient area of acceptable soil for required drainfield,and/or Reserve Area.
6. Proposed system too close to well.
7. Other(Specify)
()SE Form G(pg.I)Revised 7/02/2009
i
Page /d of ijc/
Date of Evaluation: 0tI/O6/toIS Profile Description
SOIL EVALUATION REPORT
Property ID. T x 2 / 3D
Where the local health department conducts the soil evaluation the location of profile holes may be shown on the schematic drawing
on the construction permit or the sketch submitted with the application If soil evaluations are conducted by a private soil scientist,
location of profile holes and sketch of the area investigated including all structural features i e sewage disposal systems,wells,etc
within 100 feet of site(See section 4)and reserve site shall be shown on the reverse side of this page or prepared on a separate page
and attached to this form
e✓5 e application sketch See construction permit See sketch on reverse side or page attached to this form
Hole# horizon Depth Description of color,texture,etc. Texture
(Inches) Group
J R 0—N 7.sits"! Sr,,.,.. CI L.»,„ �—
RI- Y- So 2.S . IR.1 �, L�./CM
C SO-74 7.s YAS/i. Shro.3 2 rio..,.n l,7h 4. (I Ins..., "ICC
Z 4 0-q 7.sy1.313 Bro..h- Cfar I.Awl
gi- Y- II y.ryArk. ,lad e/,ii..",....
G3 lit-if, 5us1/4 yell
.awl.NA 4I 47kk Chy i.....,
3 4 0- s _le yM-fr P►9,fk 44'47(AL n&o w,. La"v,
84 _,C- /7 1OYa`f' Brm,.,,. I, 1%o6..., L''LI Che, tesp,+l
tit" —Ss SVe rJi. ,-110,..,ems C, �4 I C�/..p Lem
CB SS-96 Uw►..7 syz'fg ya.04,n�c, iz. ' 2.r�i/c
R.1 ; 7.ryklic s1-r0.3I O,an ir,dtL day le,w.,
REMARKS
OSE Form G(pg.2)Revised7/02/2009
•
Page </ of /r
Design Calculations
Property ID: "At /4'p ZZ psrc4 31)
Flow
Type of use (residential, etc) ReSclsniag Show Calculations Here'
No. of bedrooms: 38R
No. of employees: q//A
Square Footage of building space:gao .J+•
Daily flow (peak design) in GPD: 1/06,pD
Treatment
No. of septic tanks: I Show Calculations Here'
Size of septic tank(s): /poll 1c11ii n
Pretreatment required? _yes . '
If yes, specify type of treatment device:
Absorption area design
Soil Texture Group:MC If pump system, enhanced flow, or LPD show
Reserve area r��..l1uired?_yes no calculations here or on a separate sheet.
_ 50% -/100%_other(check one) (dosing volume, head, pump design, etc.)
Specify other
Water Supply
Class of well:Ey;st p.;lkl i q Describe (bored, drilled): eve S44„ DI;►LJ 4,JelI
Distance between septic tank(s) and J
well: $ '+
Distance between absorption area and
well: ►jM f
Information and calculations required for commercial and/or conditional use applications only
OSE Form I Revised 7/2/2009
Iy
Abbreviated Design Form Page /e.Of
This form is for use with gravity,pump to gravity,enhanced flow,and low pressure distribution(LPD)sewage
system designs and when applying for a certification letter or subdivision approval.
This abbreviated design covers the ❑ primary and reserve area, ❑ only the primary area, EIonly the
reserve area(check one)for 359J Awn
ivy
l .St,►,ka, / d (property ID).
I
Design Basis
(06,
Total length of available area: ss Total width of available area:
Estimated Perc. Rate: 5.5- at 78 in. (depth) Number of bedrooms(or GPD): 30X or 9.57,4fr)
Conveyance Method: 66107 v; / Distribution method (specify): 6r.9ye/ Wench
h
3 �- _
Dispersal system basis 7NIJe S,f a //SVDR LGMI required? Np (Yel
Effluent quality required: ?iivisry Secondary,Advanced Secondary)
Square feet per bedroom: V/Z sy,f�j,�� Total trench bottom area required: /Z34 s�•4.
Gravity,pump.siphon
Enhanced flow.LPD.or Drip Dispersal
Table 5.4 of SHDR or identify the GMP used
Area Calculations
Number of trenches (Note if a pad is used) Length of pad or trenches: 5-6-
Width of pad or trenches: 3' Center to center spacing: 9
Reserve required? Yef Percent reserve area required: /Oa
Total width of absorption area required &t Total trench bottom area provided: 3ZO
The required width is calculated by multiplying the center-to-center spacing by one less than the number of
trenches and adding I trench width plus any required reserve area. If the topography is not uniform across the
length of the site the trenches will need to flare apart on one end to maintain contour. When this occurs it is
necessary to use a center-to-center spacing that accounts for the flair or the installer will not be able to fit the
system within the approved area. It is perfectly acceptable to have more area available, especially up and down
the slope,than is required.
OSE Form E Revised 7/2/09
Page /3 of //
System Specifications
Property ID: T x AT ZZ force) 3D
Applicant Information
Name Hews of chi i y G. A 1,,,,J Phone 4/39-9'04- 7/47
Address 3S9/ gur n l er S+,ti;o„ Koad
73w1boL,r.vdIe 1/4 Zz93L
Location Information
Tax Map No. ZZ ¢� f 3p Property address 357/Burnlc1, S/nhoh gaej
GPIN No. 14rDeurau'//e. f/# ZZ932,
Directions Sr,.,.f l s,�� Po,,,fe. G y/ Subdivision R,41,94.4j ichwly
Section Block_
Lot p
General Information
System Type Number of bedrooms 3$R
(e.g. septic tank, drainfield) Daily flow 1/5-0 c FD(gpd)
Type of property i,.h};pI
(e.g. commercial,residential, etc.)
Conditions
Sewer Line Septic Tank-Inlet/Outlet Structure
Schedule 40 PVC, 4" �or equivalent Capacity: 1000 gallons
(add check or describe equivalent below) 2nd septic tank eV/A gallons
Per the 2000 Sewage Handling& Disposal
Regulations, Check which option chos n:
Septic tank with inspection port ✓
Septic tank with effluent filter _
Reduced maintenance septic tank
Conveyance line/force main Information Distribution box Information
Method G,e,mi,y No. of boxes l
(e.g. gravity,pumping, dosing siphon) No. of outlets /Z
If pumping, attach Pump Spec Sheet Surge or splitter box required:
Material ..546 / 4/0 PVC Yes No ✓
Pipe diameter 5/"
Slope of pipe(,"-/ap' (in inches)
Header line Information Percolation line Information/Absorption
Area
1500 pound crush strength Yes f Center to center spacing ft.
Minimum slope is 2"/100 ft. Yes Required spacing ? ft.
Installation depth 7$ inches
Aggregate depth/3 inches
No. of Laterals $ Lateral length .5-5-ft.
Lateral bottom slope/-2-inches
Lateral width 34 inches
OSE - Date DS/ALIA°i8
OSE Form J Revised 7/2/2009
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