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HomeMy WebLinkAboutSUB202000057 Study 2020-04-08 Christopher Perez From: Donna Price <donnapaulaprice@hotmail.com> Sent: Wednesday,April 8, 2020 4.15 PM To: Christopher Perez Subject: SUB2020-57 Price - Family Division Attachments: Well septic 19991202.pdf CAUTION:This message originated outside the County of Albemarle email system. DO NOT CLICK on links or open' attachments unless you are sure the content is safej Christopher: The 1999 report approving the new septic system for the existing house. Donna Price 757-617-5325 Donnapaulaprice@hotmail.com 1 ilgi 15R3 • • • • • • • • . i • . ' • • • • • • • • iA !. -- — -— —--- - .� - I D-5 ski p f Completion Statement . Commonwealth of Virginia • • . TM? ', 5_. 5- State-Department of Health. . - - ' ji 'Health Department bi Identification .Number (U ( ��- (1 f - Health Department Name of Company/Corporation/Individual: el--- SW' *. oI� :'g_o-p. tw� 3 4OUI'SA As t '� n -• (-15/14_-) �,S- S I O Address: l ,�'elepho e S l el Owner's Name 1 - - ' Owner's Address ' `'e K 1:1oU`Q _ - i Location of Installation: Lot • - - - - - • Block --- Section: • - - --- - - - ubdivision: - Other: 0 --tsL�' 0,1), s C o _ 2��02 S i�A �. � `Q oq y� �"a 'herebycertifythat the onsite sew ' e dii tem has been installed and' completed in accordance with the con- struction permit issued (date) 5r 7.t. ) and is in co !lance with Part f the'Sewage Haniiling and Disposal Regulations an when appropriate the plans and speci ' ' s the pro' c . /v2 -' 01. .- 5 ,e , . Date Signature and Title C.H.S. 203 Rev. 4/133 'r t • :; •iv . , fit , i,.,•G_ . ...-1 t:,.,s.. . 3.At;; • ' , .. _ - _ �..�a.C,.;CL `t.•Ll;,• I V .,`.. �� (Cr .�. ) .r � .�� -.�� _ .� f.. ..�' • • 1 L `fIG fir..•►...Iv t paL£;'A C. i'''. 11,:-} (f:.". O'J2It:3 f•.-,.i.E.' 1r1 cv?Ilaat: • ' 2...L• pf, : rf..,-:-.11 1..-: :nc , $l 4: cc,....-bier. .a 1' {; OW- e:..L.ICL: --.--i".-- r,-p---z5z------2-4.. r„r.-44- i 1-.:i f"7-77-ci• - .• 4-1 , \t l , %. 1 C. - - -.--- _. -- --...._ __ - _ _ _ - - ------ • . • 1 • C. fli 1 N• ......i .-.-_•r - _.r_ - -1 - "a."*"..;'. 71 cowhENA\coLb^L%; f t\jUq!Algi . _:v r .77F -, �.. ' J j i r-"_ r-- , `� • 1 1 1�r__. ._- _�� _.. • h • - - /^..r�I¢fJ 1y..� .,f Iffy iqVt+lytM!OU 's,,+a-ii031. -.‘ r ti _ — a e i.• \ 40 •, • - • • 0 0 • • • 0 • • 0 • • 0 .L..-'.-' t. '• . . . . ..... 4 • „ , . , 4 ; . ( ` ! ` 1 _ ! ID-5 . ' Completion= Statement K j-P .', . •! ? 3 'i• • - - • Commonwealth of•.•V.irginia' • - • - • . . T • ' ti p f/ S"" J- . . State Department-of Healthy • • z'• . . k JAN 1 8 2000 Healtn•Department / 4 '_. w• „d:— Identification .Number • ENVIRONMENTAL HEALTH + • - t: - - • Health Departme�_ l. ' . Name .of. Company/Corporation/Individual:- • ei--- ���""` a 6(040k4.21M1 co I-ov,!cA PQ ; L' 0.4 o5_ -s -0 . "' Address: l y 'elephone: � �' '� � c ' �� . - . -, , Owners .Name' s4: -� - -• • . fi . Owner's.Address 54M''4 fr A V - - - •- Location of Installation: . Lot • Block • - y Section: - Subdivision: , - • • • • P4i4 . c9.o`fs�, r L 0)i �s. D Other: ca?��� � � �`' ` '� �� S I hereby certify that the onsite sew a disposa s , tem has been. installed and completed in accordance with the con- • struction permit issued (date) and. is in co •Hance with Part -of the Sewage t Handling and Disposal Regulations and 'when appropriate the plans and specif',. . i• s • - the pro' I /02 - . -- 5 r -�" . 4 ......------ Date , _ • _ Signature and Title C.H.S. 203 Rev. 4/83 - 4 - r-- - .'gL i..• ...'.L.. I . 771' �� - Cothiiletion Statement -' :, Commonwealth of Virginia • + 17-ni I /I5 - i State Department of Health - xHealth Department / 91- r�J� r� J'� identification Number. FA Health Departme... 6Y.o4; u PA-411 Name of Company/Corporation/Individual: e/- S '' `� s Address: (-ag 9 / 3UAL PCQ ) ESu) I( arelephone: ( 7 g' VS OOwner's Name `s '92 .S Owner's Address S.l4 ivR`'e NS l a6 ti cle Location of Installation: Lot Block • _. Section: _ - Subdivision 2 -0S .Q � S �C°o 1 L� � A . 0&ic5ioOther: ? 5 z� I hereby certify that the onsite sew a disppsat.system has been installed and completed in accordance with the con- struction permit issued (date) X /U 7 and is in co Hance with Part D f the Sewage Handling and Disposal Regulations and when appropriate the plans and speci ' s the pro . /0,2 - 0- - C 5 Date , Signature and Title 4 . r, C.H.S. 203 Rev. 4/83 41 Water Supply and/or Sewage Disposal System Construction Permit Page-1 of / - Commonwealth of Virginia Health Department Department of Health .Identification Number: ._ 101-99-0527 ALBEMARLE CO. HEALTH DEPARTMENT Tax Map Number: 115-5-120 General Information BP/: 99-1481 AR Water Supply System: EXISTING Sewage Disposal Systems NEW Based on the application for a sewage disposal system construction permit filed in accordance with Section 2.13 E, of the Sewege Handling and Disposal Regulations and/or Section 2.13 of the Private Well Regulations a construction permit is hereby issued to: Owner: DAVID J. MRAS Telephone: 804-960-4381 . Address: 5972 T C WALKER ROAD, GLOUCESTER, VA 23061 For a Type I Sewage Disposal System or Well to be constructed on/at NORTH OF ROUTE 708, 0.7 MILES WEST OF WOODRIDGE MKT Sec/Bk Lot Actual or estimated water use 300 gpd - 2 bedrooms DESIGN NOTE: SEWAGE DISPOSAL SYSTEM INSPECTION RESULTS Water supply, EXISTING WELL Water supply location: Satisfactory /Iyea no^_ EHS DATE Building Sewers I.D. PVC Schedule 40, Building Sewer: Satisfactory yes_ no_ or equivalent. Slope 1.25" per loft(min.) .6. A l 5-t i n Other/ EHS DATE / septic Tank: Capacity: 750 Gals. (min.) Pretreatment unit: Satisfactory yes no Other 10 OD EHS DATE Inlet-outlet structures P C Schedule 40, Inlet-outlet structure: Satisfactory yes no 4" tees or equivalent. Other _ - EHS DATE Pump and pump stations Pump & pump station: Satisf c ory yes_ no NO - EHS DATE ....7 / Grraelt! mains(: 3" or larger I.D., min. 6" Conveyance method: Satisfactory yeee no__ fall par 100 ft., 1500 lb. crush strength or equivalent. Other - EHS DATE Distribution Bear Precast concrete Distribution box: Satisfactory yesj no with 3 ports. Other. EHS DATE Sender lines: Material: 4" I.D. 1500 lb. Header lines: Satisfactory yeeJ(no_ crush strength plastic or equivalent from distribution box to 2 ft into absorption trench. Slope 2" min. Other EHS DATE Percolation lines: Gravity 4" plastic Percolation lines: Satisfactory yesJno_ 1000 lb. per foot bearing load or equiv. ' elope 2" - 4" (min. max.) per 100ft Other EHS DATE • Absorption trenches: Absorption trenches: Satisfactory yee,no - Sq ft. required: 600 depth from ground surface to bottom of trench 20": aggregate size .5-1.5": EHS DATE Trench bottom slope 2-4"/100 ft center to center spacing 09 FT: Date / 6 App ed by: • Trench width 36" Depth of aggregate 13"s Trench length 100 ft: Number of trenches 2 : Envir ' ntal Health Specialists C.H.S. 202A ---- . . .. . - - , , • i Page Number 2--of 3 Health Department / U,'— �,ter'— �Z n Identification Number Schematic drawing of sewage disposal and/or water supply system and topographic features. Show the lot Ines of the holding she,skew,of property shoeing any topcgrachic?spews Visit may impact on the design of the well or sewage disposal system,Including edging and/or proposed structures and sewage&spinal systems and web within 200 feet The schematic drawing of the wee she or area urdlor sewage disposal system shall show sewer fines,pretreatment unit pump station,conveyance System,and subsurface sal absorption system,reserve area,etc.when I nonpublic&Inidng water Is to be penm'aest stow al sources el polulion within 200 feet formation required above has been drawn on the attached copy of the sketch submitted with the application. • or• i r i i I 1 I I r I I I 1 1 I +well exist' i i I r . house I I I— w exist tank �Z , 1 Install on contour -` /9-1 C> 1 1 ' -?Sa r r add 2-100'x3'lines / - - r r 20"deep ``- KKK. _• _ _ Iring i I r 9'minimum _, x3'I es ` ` -` r h - �,i r r r r , r ok to install ditches on wider centers • r 1 A r)7� I 1 �v✓ IL • . / 11.,0 VP To Rt.708 r — } I 1 .-._.._... it r i i • • This sewage disposal system and/or water supply is to be constructed as specified by this permit. This sewage disposal system and/or well construction permit is null and void if(a)conditions are changed from those shown on the application(b)conditions are changed from those shown 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 installation which has been covered prior to approval shall be uncovered,if necessary,upon the direction of the Department. Date: Issued by: i This Construction Permit Valid until Environmental Health Specialist / Date: Reviewed by: Zfic of Environmental Health Supervisor HEALTH DEPT NO: 101-99-0527 TAX MAP: 115-5 PAGE 3 SEWAGE DISPOSAL AND WATER SUPPLY CONSTRUCTION PERMITS See Page 2 For Design Drawing. Drawing is Not To Scale • Permit is void if the house location interferes with the proposed well or drain field/reserve locations. • Follow all OSHA requirements. • Minimum separation between drain field/reserve area(s)and well sites is 100 feet from Class IIIC wells and 50 feet from Class IIIB wells. This distance increases by 25 feet for every 5 percent slope for wells down slope of any source of contamination(house site,drain field/reserve area,etc.) • It is the owner's responsibility to ensure that the well and septic system is on the property and does not interfere • with utilities and easements. • Health Department's Operation Permit and Well Inspection Report are required prior to occupancy. • All septic and well contractors must have a current license with the Virginia Department of Commerce. • It.is illegal to put either well or septic system into use without final health department approval. • Septic and Well Contractors should be provided with a copy of permit before any construction begins. • Well and all water lines shall be disinfected prior to water sampling. • Dry holes must be permanently abandoned in accordance with the Private Well Regulations by a certified well driller. • Basement(floor is below surface of ground)? YES NO Walkout : YES NO • Fixtures in Basement? YES NO Lift Pump Required? YES NO • Is septic tank location in a place of suspected high water table? YES NO If yes,please refer to tank manufacturer's instructions on placing tanks in saturated areas. • Pump is required when the ground surface over the drain field trenches is at a higher elevation than any plumbing fixture or the sewer line leaving the house. • Do not disturb the drain field or reserve area(s). • No buried utility service shall be closer than 10 feet to any part of this system. • Do not install drain field systems during periods of wet weather or wet soil. • It is recommended that all trees be removed from the drain field area and all hydrophilic trees within 10 feet of the drain field area MUST be removed. • Place untreated building paper or approved material over the trench gravel. • The maximum soil cover over septic and pump tanks and distribution boxes is IS inches to 24 inches. • All tanks shall be watertight. • Final grade of drain field shall be crowned to divert surface water and prevent pending. • Roof drains,basement sump discharges(non-sewage),floor drains,footing drains,discharge from water treatment systems,etc.,being connected to this system is PROHIBITED! Divert these away from drain field. • Keep structures and driveways off drain field/reserve area(s). • It shall be the responsibility of the owner orany subsequent owner to maintain,repair or replace(requires a• permit)any sewage disposal system that ceases to operate in a sanitary manner. ALBEMARLE COUNTY HEALTH DEPARTM :rI1 P 0 BOX 7546 -- CHARLOTTESVILLE, VA 22906 January 6, 2000 DAVID J. MRAZ 5972 T C WALKER ROAD GLOUCESTER, VA 23061 RE: PERMIT ID # 101-99-0527 DEAR DAVID J. MRAZ: According to our records, we need the information checked below to complete the final approval for your septic system and water supply. This information must be provided before an operation permit can be issued or an occupancy permit can be obtained from the building inspector. Please check with this office before requesting an operation permit to see if we have all necessary information. They are as follows: A completion statement from your septic tank and drainfield contractor. 2. A final inspection and completion statement from your sewage pump system contractor. 3 . Your well must be disinfected and a sample must be forwarded to the ALBEMARLE County Health Department with thet be Sewage Disposal System Construction Permit ID number. Please contact us if you need a list of State approved private labs. 4 . A water well completion report from your well driller cased and grouted at least 20 feet deep. 5. Well location needs to be inspected by the health department before an Operation Permit can be issued. please-call 8b4-972-6259.stions regarding these requirements Sincerely, (1 Wi (.-Ctilfir •-• ---) liam A. Craun Environmental Health Specialist Senior Page 1 of d`=-• - DATE: 49. ID #: 101-99-0527 ASSIGNED TO: William A. Craun OWNER'S NAME: DAVID J. MRAZ p SYSTEM TYPE: - DIRECTIONS: Q fr Sit 7-v'b WELL TYPE: . .I TRENCH DEPTH: Z ( rZ`�`� # OF TRENCHES: �:wd— DEPTH TO ROCK: LENGTH: DEPTH TO WATER TABLE: CENTERS: r "i 1 ' DEPTH TO FREE WATER: SLOPE: 70 /LANDSCAPE: Li TEXTURE GROUP: PERK RATE: MAIL TO: H# Hz DEPTH DESCRIPTION TEX. GRP (Q1- -9=-2 — a, fir- i3 7 .s (tr 3 �3-y 2 6, S �— $ cert.- c`c y4 3 • P/4 c SIGNATURE OF EVALUATOR: ` ~ . ' . . ' ' . . ~^ , . . v . � . , ' ^. ^ ^ _ ' - / � ` Thomas Jefferson Health District Albemarle/Charlottesville Health Department Environmental Health Services Application for a•Sewage Disposal and Water Supply Permit ADDENDUM TO BE COMPLETED BY APPLICANT Directions to•the Property, fl C i ac.i[m tn.} Building/Facility: Intermittent Use [ ] Yes [gig; Termite Treatment [krYes [ ] No RAN". Water Supply Public [ ] New • [ ] Existing Private [' ] New (Existing Describe • Attach a surveyed plat of the property showing dimensions of property, proposed and/or existing structures and driveways,underground utilities, adjacent soil absorption system,bodies of water,drainage ways,and wells and springs within 200 feet radius of the center of the proposed well or drainfield. Distances may be paced or estimated. _THE PROPERTY LINES AND BUILDING LOCATION ARE CLEARLY MARKED AND THE PROPERTY IS SUFFICIENTLY VISIBLE TO SEE THE TOPOGRAPHY. I GIVE PERMISSION TO THE DEPARTMENT TO ENTER • ONTO THE ROPERTY DESC'.':ED FOR THE PURPOSE OF PROCESSING THIS LI ATI N. • 7 - 2') - SS Signatur- i f Owner/Age Date FOR OFFICE USE ONLY f -Health Department ID: 101 —Clq 0 )_ 7 Q Receipt Number: q Qqq V Date Application Received: j PC toa&eiGar chef • n.-•n.'• 4-.1-r+ti«,•-r •,_ -.'t'Ne'`4 •0'7".,.-,1i_-_!.•4.•A • 1 a 'i,,'.•ri „...� i r •?•• - • `-!_ , .,.,..•. - ..._ r - .• .i_, �. • • Thomas'Jefferson Bealth,Dis• tr�ct •' Albemarle/Charlottesvllee'Haltl D 7. epartments r • /? ?' ' • ' .� Environmental Health Services i►" ' • • • Application• 'for a...Sewage Disposai!and \Vater.,Supply Permit t• / .' .. +.' •` `"''. TO BE'COMPLETEI BY°APPI:ICANT o ''�'"�" l . r.- fli . . " • , ;Directions to.the+Pro pert n ( al i ;�mt t} p Y �� y •N .., . •.• . .17 ' ,,Pr- . , .Age/ATOPP ---- • ,.' ,,- , : •-.., . • .. • . : .. . f.... ..;•...., . /{ il r acility "N'�`r J.,Iri • [ ] Yes'.. 5�,,,.t' "i C- • '• '^ w • • . ,,.r.iy+ ent , r -- '[vr••es -• ,•.[ JJ N�o 'U1S'U1. - , , l(; .Water:Supply,/ Publ• i /. '•� • ' Existing' ' pl • "; , ' 4r •,- Y•;T,. ' S '•' ;C; I '?fF'Y' ,,,Per, N•,•ti,5!":,9�yr�.e'['']�1\e{v ['_ ] "sting ..• ,. ! , .. � :Fr.•1 . • j . .�;,•• Privatel,t•••j!• r.. • ,/''ts�„�.,;.?'.":..q;►1 -N{env;=}: ., Existing ,,•' • • •-�,4.. • • • • 1. C .! Describel'M.,, J.?•:•i' <r' 1 • • • .:. .g::..• .4 •I. :• . i '„;', _ '. +Attach••a•surve-'ed•, la "� 'a`'" ' '�`�,<.„�'� . �•.• , • '•' , y p t•of the-propertyshowing dimensions of property,proposed'.= ` ' %,,^'.and/or existing structures and driveways,unilerground utilities;adjacent:soil,. i,• �' abso lion'system,bodies of w`ec ( """""'" --• `` , r '•w...41.k''' .';'• `• ,.. ,•• ' . .• • . . • rp y t , �w . at, •,drainage ways, and-wells.and'springs within.200..• , - • • • , , feet'•radius:of the'center of the proposed well,or. drainfield*Distances•imay�be'paced .;. :, t or estimated. ;. , , _.iu . F • .; '' • • • fi -4* '' r 7..OTHE PROP• ERTYL IN- ESrAND BUILDING LOCATION'ARE.,CLEARLY, '• .. • ,•,-- • ,,, ,.,.•MAR{ED AND THE•PROPERTY-IS SUFFICIg.N.ii�Y�VISIBLEiTO SEE lI E' - t..1TOPOGRAPHY;;I'GIVE-PERMISSION TO THE IDPARTMENT TO ENilkfi r ' ' • • ONTO THE ROPERTYrDESC..::ED FOR THE,PU'RPOSE O '+PROC G • , ' • . • THIS I ATI 11Ts'.::. i,1 • ;.. f 7 ,:r, :� . ......^-•'•"..�: •..,.�,.,+.I .•r �• .• '�,I ..' .., ,1 '...7 7y \car • ' '�. •• • 1 . �J/� 7 2/) ' ./ ; • ' • • -' Signatur f i wnerlAgen • r .. . ., �' _ Date' , h • ! .' . -FOR-OFFICE USE ONLY, ' • t - - Q • Health Department LD 101 — .•-4:: ' CO 9 , ;. '' �1 f� t • , ;' '.: • Receipt Number:. Z 'V ' 1�"( Q 4 . ;• . . . . • Date Application Received:: ,i/''' C !/�, pq }' r Chcc lc- ` •.. ..r,r .. - ,. • • - •1 ,r .x'" 4i,:*A••• ,, .' 1 ,... ,• 1., �� i Date 7', % l County.of Albemarle /1500 --DO 'e0—005.06 • :- _l AI.% BUILDING PERMIT No Stottgig Land Use . Yes. Building Code and Zoning Services �� 198/ " � `� ®. _ Permit# 9 � PERMIT PAID: CK CASH •►� 401 McIntire Road OTHER i lr„ ar Charlottesville,VA 22092-4596 Project t#Tel. (804)296-5832 • Fax(804)972-4126 _ I' • I. NAME D�u I d J - H rr t O NAME ff. / e eJ e.rkar re ADDRESS cgr73 I G G�&+ k'er Rd_ ADDRESS _IZI— A �to% 7 3l ' ILIZ .;�-^ V '7 rl f OS CITY_ 5t&� /, M Be. , v ► d 7 S1 D t., O CITY gmu� S l �I Qt �V� l Z PHONE � � M � � " PHONE 960- 3 UI (pQ O V State Reg. County Exempt.^ Type of Frame Type of Water Supply Z �,f� yj ir , W NAME 131 5 &4..1I�f hlil ❑Masonry Wood O Steel ❑Public [�pdCate 0 C.Well J (�� u�� /r /� Type of Heal'urglMechanlcal Z Type of Sewage Disposal 8 ADDRESS r 4 �J�f / " E ❑Oil 0 Gas ❑Elec. 0 HP 0 Public i iC V_ A l �,�y Wilk, (/ / ❑Fireplace a❑Wood Stove CITY ,hA !o1 . V 4&�!D� ❑Other NI o Gas Logs • = Class of Work:� W PHONE 1.7 b a a ?., . o NEW ..OYADDITION 0ALTERATION O Other 2 Describe Work: a lid!*04% -6r sbed erns/I bit l Ids ai3Lpow - n No.of Stories i Sq.ft. 1st Floor 5_20d Floor Garage ' Fin.Basement Unfin.Basement Decks ASV Porches/9e PROPOSED USE -SET BACKS - Crawl Space ❑Slab Engineering , Front Zoning )• i One FamilyBedrooms Baths Back Value of Work !� Permit Fee / Garage i" Carport Kitchen R.Sd. 5g, 00`` 1%Surcharge 1 , L.Sd. Total I VV -- Other .pr.-t f all6f,/ eL Floor Type of Use Zoning R it Dist. ,9 C t v� School Dist. Const. Group Live Load M �+nt7 f 5 y•/7 Size of Bldg. No.of I Max. Tax MaplPercel 1 �0)'t'v"�� Acres 7!" (Total)Sq.Fl. Stories 0cc.Load Lot Bik _Sec. Phase No.of No.of Accessory Fire Sprinklers Required Dwelling Units Structures 0 Yes CI No Subdivision . Zoning Pre-Construction Building Pre-Construction Fire Alarms Required Plans Reviewed By Zoning Approved for Issuance Building Approved for O Yes 0 No 0 Yes 0 No ❑Yes ❑No Issuance By SPECIAL APPROVALS REQUIRED RECEIVED NOT REQUIRED Zoning NOTICE Health DepL 1� SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, Engineering VENTILATING OR AIR CONDITIONING. THISPERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED Service Authority IS IYOT COMMENCED WITHIN 6 MONTHS.OR IF CONSTRUCTION OR WORK IS Planning t/ SUSPENDED OR ABANDONED FOR A PERIOD OF 6 MONTHS AT ANY TIME AFTER Highway Dept. . WORK IS COMMENCED. PreliFinal Zoning I HEREBY CERTIFY THAT HAVEREADAND EXAMINED THIS APPLICATION AND KNOW THE SAME TO BE TRUE AND CORRECT ALL PROVISIONS OF LAWS AND ORDINANCES Recorded Plat GOVERNING THIS TYPE OF WORK WILL BE COMPUED WITH WHETHER SPECIFIED Sile Plan f HEREIN OR NOT. THE GRANTING OF A PERMIT DOES NOT PRESUME TO GIVE — AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OF ANY OTHER STATE OR ARB >✓ LOCAL LAW REGULATING CONSTRUCTION.OR THE PERFORMANCE OF CONSTRU ION. 7 "REAL ESTATE DEPT. APPRAISED VALUE �: �./ 7//1/7 LAND $ l • EOFCOJrRAC OA AUTHORIZED AGENT ° / BUILDINGS SIGNATURE OF OWNER(IF OWNER GUIDER] DATE TOTAL $ I' 34 rf E„• 197.04 irpn R @ l5 I Vf R 313°49401 r _,: 43.09 E 59.34 SO4•1:' • �'' �: 's• 1111 ,sf.oe 13e.00 Pr. 0 '� ". to,!e"w 136.79 RUELDiNG�CORE&ZONIN Power G SER7 LH° 0f'23"w of.00 � ,/� „ .• 0v 11 1 te'4 F5,14t"w r28.35 —9 q __it/0 ee.9e /� ! eqo Off,A Et IA 1 • 0 0!'le"w fe0.lr ° N wtfl� . III R.O.Mbr cit a •a3i 12'U"W 49.90 ' l 3licyFreme.' l J, o Iron set a ° `&r 7e S?'E7"E 47.00 • Fran+.8dlelnq ` .�o , 1•• v 16,Q»E t42,3! : re'stile Sir. Nw 21feW . 47.90 LAe PtC „1 Ne , + • PT. C , ' �� J,, ., , YO ) a�'I moo h,3 tPi '?3 4� • . 1•. \':`"� Emitting 3t?. \ 30'Prlrafe Aeeett O rlrade M. Logs. \ \ :sentD9.52! • 399 ' � \ • ip % • • i T.M. 115 PARCELS •�• : PARCEL A-I - P • ,=•- . ' D.B. F41 • 731 • \ 3 Q''de. F41 • 73e Plan. -'. , r: f , Ernest n—a % _b. t 8 e Ny J. Dan�eron t . • • { ar 41 1 09. 70e 441 \ ° 1 Oe. elr;•IRO y • ,, . `•`\• 0 Jlu* •' N' ',.� rks • ` ` , M7,O 11 • yu f ?i Ps iv �'4, J.B. ArrnIeHad • j f •• D.B. 290 ' 27e PT. A • D.B. 81 WO Plat LINE • PT. A • ••; • I 'SQ W. 4e.12 • ial - • . Private Aee.el ' NOTES: ' • Ennt, �'N"E r01 ae• T41 • TN • O. TRIO PROPERTY DOES NO_"f:rt;t ITNIR rme. . • ''04"E •.: ' I00 TEAR FLOQD PLA*ACCORV1NO TO TN' 'a•E •• FLOOD INSURANCE RATE NAPS. - . est 1 er ;�, '� -, :► • I • , t. TELEPHONE MESA• THIS AREA ARE . } • UNOEROROUND. ter - i p�■E .p'� 3. C DENOTES IRON POUND. . j • a111 - ••r, . '�' '! • NMI.• t ';• , ilk • ieiti• f . ' . "Jr A•,,.- l PHYSICAL. St1RVEY • • • ' f t fis* ` 31r 4 :; ,, a _ TWO-Environmental Health Services -_ _ _ J q ! ARP.O.Box 7546;Charlottesville,VA 22906 REQUEST FOR NEW CONSTRUCTION WI H EXISTING rWAGE DISPOSAL Owner's Name: 1F10 i"` CO(^' 4ift '? 1 Agent's Name: . ` . • Agent' Z'I• �`tJ� �L * COphonell: 4•� ( � 1 �S Agent's Address: es..7, ' � i � � L .p� p 0(43, Day#: `�C• - �• O -U 331 ads V �' �� y�t{�Ci 0 Lot: Block vrsio Site Identification: �u r� �� � �p Tax Map II 1 Building Permit# /1 I Q7�1], Directions to Property. <-0 is kS .# \lawe�` S k;p `,t 1 h . 1k ytl Q:k- l_.0 1 K ' C?•N .- 1 "40 C12F dam\ liP:7 -A-C fLL0)11.1-oN 55 Le—— ctAk )2-1 p4- II' k- ' 1 Up Ckvt.t.k +-E-c A kk o t' la U S-4-6 Ck ''\~ Proposed New Construction:CA" 90% 5A/ &AA .Ge c .Lsk Ma `Boy O)O Sa sat . ..©N - y 11-1—.--u 2til 11:9 ti-4- i° Vf o ,M be +t-o Vo a-k 4- 4-14 L F\- ?a0W4. 4,t0c), /� l r00� 'I S s Please answer the following questions: �"'Q` �� Circle One 1. Was your septic system installed and approved wiiliin the last 10 years? Yes or No 7 2. Does proposed addition or replacement encroach upon the drain field area? Y or No Z 3. Does proposed addition or replacement come within 50'of your well? • 4.47 or No 4. Are there wet spots in your yard,slow running drains,backups or discolored spots in your lawn?Circle those t at'apply to your situation. 5. Has your septic system been pumped in the last 5 years? Yes or No ? -7 /4Ls!c 14.-.---- - . Date ApplicanUAg 's Signature (Note:By signing this statement you arc requesting that the Environmental Health Specialist evaluate your system and are gaming he/she permission to enter your property.) HEALTH DEPARTMENT USE ONLY • i Existing sewage disposal system should be adequate to handle new construction and use as above. Building permit may be issued. Existing sewage disposal system inadequate.Applicant must apply at the health department for a Sewage Disposal Construction Permit to be issued before Building Permit can be issued. XOther AP ROVt • ith D artment Records and/or Site Visit Findin s: tssucd -k3. Ctndg Scph'c, stISi%LI 101-qc.-- osar7 8 it 9 _ ,fillittia ate Envir mental Health Spectallst 055 . ♦ . 2 .' TAG SHEET = . . _ _ Permit I.D.#: 101 — q Cl - d5 -1 Owner: U It i . 1 l 1 ral Z Agent: _ Tax Map #: 1t5 `ZD Subdivision: - Lot: t. • r {} Combination Permit {} Repair Permit {} Septic Permit {} Well Permit {} Well Abandonment {} Certification Letter DATE INITIALS •S j( Application Received � {� .�, `Assigned To:Ca-tun( - . �' , Site Visit Scheduled ' WI l . . Time: t•C0fl.30p:IU • .Ct-i(JI?CSC?t1) Comments: • - Site Visit Rescheduled Time: • Site Visit Made `--r r Date Given to OSS ,71d ‘0(--- Data Entry Construction Permit {} Issued {} Denied -------- Certification Letter {} Issued {} Denied Survey Received {}Yes {} No . • Construction Permit Mailed ` - Construction Permit Picked-Up ------ Septic Maintenance = .... � . _— - -- •