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OSE/PE Report for:
Construction Permit I I Certification Letter I I Subdivision Approval '...--f"*"
Property Location:
911 Address: City:
Lot E Section Subdivision R,jl'p,,� /ry J%
GPIN or Tax Map# ZZ p�q SE Health Dept ID#J
Latitude Longitude
Applicant or Client Mailing Address: D
Name: AtC5 at /coley 6. A$11► cr
Street: 3511 ffuee /L, ,O/19n 424d
City: Bigfiourstirlit State Zip Code 22932_,
Prepared by:
OSE Name kVHinA„r'V /,.r, LLe 9.39-2y9-0292 License# /9YooO
Address 7).d- go, 75 '
City keSt. ea State (49 Zip Code Z29'5/7
PE Name: License#
Address
City State Zip Code
Date of Report OS zitfroly Date of Revision#1
OSE/PE Job# Date of Revision#2
Contents/Index of this report(e.g.,Site Evaluation Summary,Soil ProfileProfile
I-Z 05E € I t id P1n I ' ) Pat, h.ohlkns)
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Certification Statement
I hereby certify that the evaluations and/or designs contained herein were conducted in accordance with the Sewage Handling and
Disposal Regulations(12 VACS-610),the Private Well Regulations(12 VACS-630)and all other applicable laws,regulations and
policies implemented by the Virginia Department of Health. I further certify that I currently possess any professional license required
by the laws and regulations of the Commonwealth that have been duly issued by the applicable agency charged with licensure to
perform the work contained herein.
The work attached to this cover page has been conducted under an exemption to the practice of engineering,specifically the
exemption in Code of Virginia Section 54.1-402.A.11
I recommend that a(select one): c nstruction permit❑ certification letter subdivision approval
be(select one)issued denied LI.
OSE/PE Signature Date Q$/Zyf/Zol$
111. 1111111111111111.111..
pre Z o�/o
Commonweal h of Virginia YPH Use only
Application for: ewa e System Health Department ID#
g y ater Supply Due Date
Owner fte v5 ol. re`„Jcy G_ ita49 d Phone 939- 906 -747
Mailing Address 3S9/ Ttwr r, cy , y,N Aid Phone
D 9 v.,be L rs osik I/14
22732 Fax
Agent 1.e;r S ,T;`v1,1 cy t . Phone 1/3 y- qe4- 7/4 7
Mailing Address 759/ Am-in Sfil- on 644J Phone
Bq,vb VA Zz932. Fax
Site Address
Email
Directions to Property: So„{lks c e4 R60.4-t ; }/- Z *ri/cs (,.sf p/ £uk 29
Subdivision i Section Block Lot E
Tax Map Z Other Property Identification 'Dimension/Acreage of Property to.6Z MeeS
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.
CiCertification Letter - onstruction Permit 13=Voluntary Upgrade epair Permit [ .Su/rl;v..;p,.t Pev;e,
Proposed Use:
Single Family Home(Number of Bedrooms 1 ) Multi-Family Dwelling(Total Number of Bedrooms
Other(describe)
Basement? Yes Walk ut BasementnYeSE11<nr Fixtures in Basement(
Conditional permit desired?QYes( o If yes,which conditions do you want?
❑Reduced water flow 0 Limited Occupancy 0Intermittent or seasonal use ❑Temporary use not to exceed 1 year
Do you wish to apply for a betterment loan eligibility letternYes *There is a$50 fee for determination of eligibility.
Water Supply
Will the water supply beD!?ub1 c e? Is the water su _ osed?
Ppll is�8
If proposed, is this a replacement well?DYes ‘ If yes,will the old wel be abandoned?Dyes D No
Will any buildings within 50' of the proposed well be termite treated?3Yes
All Applicants
Is this a private sector OSE/PE application ex to If yes,is the OSE/PE package attached? ;2es No
Is this property indeed to serve as your(owners)principal place of residence?= e 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 clearly 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
-111
p",` 3 /o
VDH Use Only
Health Department ID#
Due Date
Site and Soil Evaluation Report
(For certification letters and subdivisions)
General Information
Date: OS1z Ve.42 13
ff bewi,rie County Health Department
Applicant: µ'eZr's An ley 6. /�py�wnd
Telephone Number: J
Address : 359/ Eurniel 5#0,h(ar► £.0.2) B/hr'bt.rsvlllg VA Z2932
Owner: /I a t'cs of F`h �. /CryJrmJ Address: 337/pare L7 StA/►on l awd
Location : £.tiiSjt p/ ECE...i cif/ ; 4- 2 .n%/s ES O Ati.oicZ7
Subdivision kis„d �ymlV Block/Section Lot E
Soil Informa ' Summary
I. Position in landscape satisfactory Yes No Describe: SI /js/7pG
2. Slope 7 %
3. Depth to rock/impervious strata Max. ko Min. - None
4. Free water present No ✓ Yes Range in inches
5. Depth to seasonal water table(gray mottling or gray color) /USA inches
6. Soil percolation rate estimated Yes Texture group 0l rill �IDIV
No Estimated rate min/in
7. Percolation test performed Yes Number of percolation test holes
No 1_/3epth of percolation test holes
Average percolation rate mpi
Name and title of evaluator: -371 lei k tree G.O.O.
Signature:
Del, ment Use
ate approved: Drainfi2'trench bottoms t• se placed at, (inches)depth at site designated on permit.
Site disapproved:
Reasons for rejection: (check all that ap•'' )
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)
OSE Form G(pg I)Revised 7/02/2009
Page 7 of /0
Date of Evaluation: 0Y/o6/2613 Profile Description
SOIL EVALUATION REPORT
Property ID: �4e, 3E
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
__'S 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
A o-G 5—`425i3 it,1 s/A arm.dr. CIS t .,
8k G 2$ 2, 7k y/c A
211-Go sit s/6, YS/,, rst. 4.1 te., C/ l4s =1:r'
fJ-G 5YA.sts C�n /,s.,� =E '
BI- 4- 37 SY&t r/(. 41r.1/., ,�L kJ C 1.� b...., ILE
CB 37-S(, 7.TYKcIt .S�ror, B,ti,.r k L, /►t CI.,, Ln,or., .7=
3 Il 4-S SYK '73 /laJlrsl, Bro,a„ L'/.ai �o,s.., air
$� S- 2$ V. r. ,.1eJ S ts7a Al sti RAP sYOX
�J
Zs-40 3YR s/i f.///wecb, 1 h wf G/•y `po.., mma-
REMARKS
I
OSE Form G(pg 2)Revised7/02/2009
4
Eh
Page Sof /10
Design Calculations
Property ID: T'c AT ZZ p„, 13E
Flow
Type of use (residential, etc) R•5tj •J Show Calculations Here'
No. of bedrooms: y$x
No. of employees: pf//iq
Square Footage of building space:15)o'J-
Daily flow (peak design) in GPD:6120 Epp
Treatment
No. of septic tanks: / Show Calculations Here'
Size of septic tank(s): /Zs,Sc//on
Pretreatment required? _yes i_ t
If yes, specify type of treatment device:
Absorption area design
Soil Texture Group: If pump system, enhanced flow, or LPD show
Reserve area r quired? es no calculations here or on a separate sheet.
50% .//100%_other(check one) (dosing volume, head, pump design, etc.)
Specify other
Water Supply
Class of well: :t Describe (bored, drilled): ?.CF$ prai.1 11klf
Distance between septic tank(s) and
well: SD'+
Distance between absorption area and
well: /Ad+
information and calculations required for commercial and/or conditional use applications only
OSE Form I Revised 7/2/2009
r
Page 4 Of/b
Abbreviated Design Form
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, C�bnly the primary area, ❑only the
reserve area(check one) for T X /4"r Z,2 rein 3E (property ID).
Design Basis
Total length of available area: /20'
g 70 Total width of available area:
Estimated Perc. Rate: Sr at 38 in. (depth) Number of bedrooms(or GPD): VB/Q or iO 4PP
2
Conveyance Method : 4r)9v;+1 Distribution method (specify): CZ —Now
Dispersal system basis TWe S,t�o jt 50/4 LGMI required? /vp (YeCED
Effluent quality required: TP;mpe 'rimary Secondary,Advanced Secondary)
Square feet per bedroom: 30, .5 Ahr Total trench bottom area required: /234 ,,!'�,
Gravity,pump,siphon
2
Enhanced flow,LPD,or Drip Dispersal
3
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: 70
Width of pad or trenches: J7 Center to center spacing: ?
Reserve required? yes Percent reserve area required: /00 2
Total width of absorption area required /� Total trench bottom area provided: I ZroO �.
The required width is calculated by multiplying the center-to-center spacing by one less than the number of
trenches and adding 1 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 7 Of ZO
Abbreviated Design Form
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, my the
reserve area(check one)for 7w 22. p,s t t.iJ 3E (property ID).
Design Basis
Total length of available area: 76' _ Total width of available area: /ZO
Estimated Perc. Rate: 55 at 3$ in.(depth) Number of bedrooms(or GPD): y$R des too Grip
Conveyance Method: A mr Distribution methodz(specify): ‘iyivei Titnc�
Dispersal system basis j bk, s Y of SiiDR LGMI required? do (Ye•!ano
Effluent quality required: Pe441)7 ima Secondary,Advanced Secondary)
Square feet per bedroom: y/Z Sy.f). 4e Total trench bottom area required: IL qg 5,.��•
Gravity,pump,siphon
z
Enhanced flow,LPD,or Drip Dispersal
3
Table 5.4 of SHDR or identify the GMP used
Area Calculations
Number of trenches g (Note if a pad is used) Length of pad or trenches: 7o'
Width of pad or trenches: 3 Center to center spacing: 7
Reserve required? Yes Percent reserve area required: /4002
Total width of absorption area required GG Total trench bottom area provided: I(D8 d stk.
The required width is calculated by multiplying the center-to-center spacing by one less than the number of
trenches and adding 1 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 8 of /0
System Specifications
Property ID: 'y 07 ZZ pi4r14,1 3E -A'mrrr/y
Applicant Information
Name Nc:r5 of lucky h. Pryl Phone V3i/ -90G- 7/67
Address 359/ 31,,e )``y en4c)
t4r10„rSrdlc 1/A Z2732.
Location Information
Tax Map No. Z2 /,,„,/ 3E Property address
GPIN No.
Directions .o,.41,,,je Ql t.W Subdivision A1Js,,,41 I s. i y
4/- Z rs,ilss Fos/ a/ Section Block
Lot E
General Information
System Type = Number of bedrooms y8R
(e.g. septic tank, drainfield) Daily flow Gco 4PD(gpd)
Type of property toes;s„t;p)
(e.g. commercial, residential, etc.)
Conditions („it►p /35-1)
Sewer Line /' Septic Tank-Inlet/Outlet Structure
Schedule 40 PVC, 4" ✓ or equivalent Capacity: arc gallons
(add check or describe equivalent below) 2' septic tank A//A gallons
Per the 2000 Sewage Handling&Disposal
Regulations, Check which option chosen:
Septic tank with inspection port
Septic tank with effluent filter _
Reduced maintenance septic tank
Conveyance line/force main Information Distribution box Information
Method No. of boxes I
(e.g. gravity,pumping(dosing siphon) No. of outlets to
If pumping, attach Pump Spec Sheet Surge or splitter box required:
Material S.he�w)� I/O Plic Yes_No ✓�
Pipe diameter
Slope of pipe(,"- toe (in inches)
Header line Information Percolation line Information/Absorption
Area
1500 pound crush strength Yes Center to center spacing t ft.
Minimum slope is 2"/100 ft. Yes ✓ Required spacing 1_ft.
Installation depth 3$ inches
Aggregate depth /3inches
No. of Laterals 4 Lateral length 70 ft.
Lateral bottom slope 2-3inches
Lateral width 36 inches
OSE Date 0S/L1/2o/S
OSE Fonn J Revised 7/2/2009
Page / of m
System Specifications
Property ID: TY /flip 22 rad 3E )?ese rve
Applicant Information
Name firs at�►'n�er &. .�ArJ Phone 4/3°/- 904- 7/C7
aViZAke_rik_y_..cfikirawid
b., e.
8AtL4rsudie UA 22732
Location Information
Tax Map No. ZZ 10.4r e) 3E Property address
GPIN No.
Directions 5,,,fl1Setic et j 61//,; Subdivision /Q,ld�,�,J roph ly
+/- 2 n,i/e. Fmsf o�toLL 27 Section Block
Lot
General Information
System Type 11L— Number of bedrooms `/$Z
(e.g. septic tank, drainfield) Daily flow(apip (PP (gpd)
Type of property e.e5 eL,,};,,4
(e.g. commercial,residential, etc.)
Conditions
Sewer Line Septic Tank—Inlet/Outlet Structure
Schedule 40 PVC,4" ✓ or equivalent Capacity: /2so gallons
(add check or describe equivalent below) 2n septic tank /25-o gallons
Per the 2000 Sewage Handling&Disposal
Regulations, Check which option chosen:
Septic tank with inspection port ✓'
Septic tank with effluent filter _
Reduced maintenance septic tank
Conveyance line/force main Information Distribution box Information
Method No. of boxes /
(e.g. gravity,pumping, dosing siphon) No. of outlets /Z.
If pumping, attach Pump Spec Sheet Surge or splitter box required:
Material SoLJ.Ale, y0 /'YL Yes_No f
Pipe diameter Z"
Slope of pipe i.//q (in inches)
Header line Information Percolation line Information/Absorption
Area
1500 pound crush strength Yes f Center to center spacing_2_ft.
Minimum slope is 2"/100 ft. Yes .— Required spacing t ft.
Installation depth 3$ inches
Aggregate depth 13 inches
No. of Laterals $ Lateral length 70 ft.
Lateral bottom slope 2-3inches
Lateral width 36 inches
OSE Date 057eei/Zolfr
OSE Form J Revised 7/2/2009
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