HomeMy WebLinkAboutSUB202000057 Study 2020-04-08 (2) Christopher Perez
From: Donna Price <donnapaulaprice@hotmail.com>
Sent: Wednesday,April 8, 2020 417 PM
To: Christopher Perez
Subject: SUB2020-57 Price Family Subdivision
Attachments: Well Septic 19960405.pdf
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Christopher:
The 1996 Report.
Donna Price
757-617-5325
Donnapaulaprice@hotmail.com
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Water Supply and/or Sewage Disposal System Construction Permit Page 1 of
Commonwealth of Virginia Health Department
Department of Health Identification Number. 101-02-0201
ALBEMARLE CO.HEALTH DEPARTMENT Tax Map Number 115-5
General Information BP#:
Water Supply System: NEW Sewage Disposal System: EXISTING
Based on the application for a sewage disposal system construction permit filed in accordance with Section 2.13 E.of the Sewage Handling and
Disposal Regulations and/or Section 2.13 of the Private Well Regulations a construction permit is hereby issued to:
Owner. DAVID MRAZ Telephone: 434-244-2983
Agent: SANDRA DABNEY Address:2852 SECRETARY ROAD.SCOTTSVILLE,VA 24590
For a Type Sewage Disposal System or Well to be constructed on/at WEST OF ROUTE 708,0.5 MILES SOUTH OF WOODRIDGE
Sec/Bk Lot Actual or estimated water use 600 end- 4 bedrooms
DESIGN NOTES: SEWAGE DISPOSAL SYSTEM INSPECTION RESULTS
Water supply,TO BE INSTALLED I Water supply location:Satisfactory yes_no
I GROUT CAP
To be installed: CLASS:IIIC
CASED:20 feet GROUTED:20 feet I EHS DATE
WELL PERMIT ONLY
V
Page Number - Z-- of"La_ Health Department
identification Number / 0 f--6 J—O Q/
Schematic drawing of sewage disposal and/or water supply system and topographic features.
Show the lot lines cribs building site,sketch et property showkra any topographic features which may Impact on Me destn of the wee or sewage disposal system.keiudkra
exidkp endlor proposed structures and sewage disposal sysbsrne end well vdlhtn 200 feet.The schematic drawing of the wet eta or ores wailer swap disposal system
shell show sewer tress.pretreatment unit pump station,conveyance syetom,and subsurface eel absorption system,reserve area,etc.When a nonpublic ddNdna water
sup le to be panelled.show al souses of pollution wthin 200 feet.
The information required above has been drawn on the attached copy of the sketch submitted with the application.
dralnfleld
NNNNNexist well
75' •
exist
house
new
‘1110.
/ 75 well 25 PL
area
25'
•
This sewage disposal system and/or water supply is to be constructed as specified by this permit.
This sewage disposal system aldlor well construction permit is null and veld If(a)condhlons are changed from those shown on the
application(b)conditions are changed from those shown on the construction parr&t.
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 Oar to
approval shall be uncovered,H necessary,upon the direction of the Departments. �,¢—
3 ' A Z Issued b : A /I. --''`-c.-' This Construction
Date: Y� Permit Valid until
Environmental Health Specialist
Date: Reviewed by: _ - 71/ , 1 o 6
Environmental Health Supervisor
HEALTH DEPT NO: 101-02-0201
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 • ease 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 • er 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 an .art of this system.
• Do not install drain field systems during periods . et weather or wet soil.
• It is recommended that all trees be remov • rom the drain field area and all hydrophilic trees within 10 feet of the
drain field area MUST be removed.
• Place untreated building paper. approved material over the trench gravel.
• The maximum soil cove •ver septic and pump tanks and distribution boxes is 18 inches to 24 inches.
• All tanks shall be atertight.
• Final grade . drain field shall be crowned to divert surface water and prevent ponding.
• Roo •rains,basement sump discharges(non-sewage),floor drains,footing drains,discharge from water treatment
s • ems,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 or any 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 DEPARTMENT
P 0 BOX 7546
CHARLOTTESVILLE VA 22906
March 19, 2002
DAVID MRAZ
2852 SECRETARY ROAD
SCOTTSVILLE, VA 24590
RE: PERMIT NO 101-02-0201
DEAR MR./MS. MRAZ:
Any water well installed in Virginia must meet specific
construction standards before final approval of the water system
will be given, or an occupancy permit can be obtained.
They are as follows:
1. Your well must be cased and grouted 20 feet
minimum unless otherwise designated.
2. Your well must be located at least 100 feet from
any drainfield, 50 feet from any chemically treated foundation, and
located on your property.
3 . Your well must be disinfected and a sample must be
analyzed by a State approved private lab. These results must be
forwarded to the ALBEMARLE County Health Department with the
Construction Permit Id number. Please contact us if you need a
list of state approved private labs.
4. A water well completion report must be provided to
the health department by the well driller.
If you have any questions regarding these requirements
please call 804-972-6259.
sincerely, i
-
•
Ctuttol. •
William A. Craun
Environmental Health Specialist Senior
Page 1 of Y DATE: l� �U[_
ID#: 101-02-0201 ASSIGNED TO: William A.Craun
OWNER'S NAME:DAVID MRAZ
SYSTEM TYPE: 2� DIRECTIONS: �Q
WELL TYPE: J G !../` c/� 51Z 7 4 €
TRENCH DEPTH: I' , (- AJO"-e4D n 1‘14C__
#OF TRENCHES: DEPTH TO ROCK:
LENGTH: DEPTH TO WATER TABLE:
CENTERS: DEPTH TO FREE WATER:
SLOPE: /L NDSCAPE: TEXTURE GROUP:
PERK RATE: MAIL TO:
I-1# Hz DEPTH DESCRIPTION TEX.GRP
ett
(C-12)t-
•
(110/
SIGNATURE OF EVALUATOR:
— - \
. A .
. Commonwealth of Virgipia
' • Application for. a:Sewage Disposal.and/or Water Supply`Per ^ �f- • .
Rabb Department ID 1 r I
, 38/6 g Ng - .
To Be Completed By The Appticaat /A 4562
Type of sewlge.zn; _New —Repair .-Cipsd _Ci.mlitsonal
-EHANA—yes nor~Case No .
d
. OwnerJ .a nra— - . Address T` t4.ar1Aa( none 49 -/nQQ ' ,
. ,Agent►Siticifal /"1 , Address,-;Sr Phone 11-o�3 ._ .
Suersy fib •
• ...le.cr stoc 14la
• Directions Property g4-a,jp :.1, ,s 41// Truce_ 'R eq .909/i r 1.4,0 ..."Ie✓ •
. • Ad& oc ?�9 �b a ict �o., er4 XV_6„ds.rtf � 4o As ,11 '- !o/7 . .
Subdivision Sectgri Block 2•ot
Other Property Identificatio at MO /• 'i I/s- . rctra 1 1l S - .
_ . _ . Dimension/size of Lot/Property S7. e1l 4CC •
I.
*
• Other Application Information • -• •
I. Building/facility. 1 New Existing . - •
-
Intermittent Use - Yes- 'No If yes.describe
II. -Residential Use' Yes No '
Termite Treatment- • ✓Yes • No •
Single Famii Multi-family •
. (Number of Bedrooms (Number of Units . •
Basement • Yes • No •
Fixtures in Basement Yes • No •
• III. Commerical Use . Yes /No Describe:
Comme_rical/Wastewater Yes • + No Number of Patrons •
- Number of Employees .
If yes, give volumes and describe
IV. Water,Supply: • Public New Existing
Private —7 New Existing -
Describe:
-V. Proposed Sewage Disposal Methods -
Onsite.Sewage-DisposarSystem: Septic Tank-Drainfleld ---..LED,_, ,Mound Other----• -
• Public-Sewerage-Syrsste i - • -
Attach a site plan(rough sketch) 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 D ent to enter onto the property described for the purpose of processing this application.,
•
G ,3'- -CS oZ
Signature of Owner/Agent )1'... Date -
:�yes —-- v o —
R . ..., / i '•-/ ,.. '-i. . 1 ! ...i....
1A
• Commonwealth of_Virgule. . "'
Application for a'Sewage Disposal•�arul/or ater Supply Per 't
� 10
. 1D�e�ID� - 3 a s/,4 a
To Be Completed Bi The Applicant , 1 3 /(' /_' .
Trl�cm _Now .__-R.. Evm _ `�' (�
ialASVA.-yam e
•
'• . Owner.'/ovtA �ic. Address TCt,C.�.1kar /.()phoney 9/, - -696I
/;/.,t,.skc./ Sill ^7
Agent n cite. I .?.�hill/ Address-a.9S07 .1t Phone 'NV-c2ca, I v / d�" 0 cX U I
Direcaons 4% roperty AV-.4 TA E -.fr�•r,-, 51,E-1 r,,. if Take R en en
4c1 /ef4- es 7:19 k.e.4c4 _r�i�•rs.44- a•e/ 7a9 ev-n s-r Alf ty -r, cad 4,:ta,f "II 4a P
lb enel-"Iliph f- Ihr4 L e 1 „fccre-1 ry At) kJ d,l v-c v,i fS ors m%/t- /o.rg. -6'.1 Ic, Liz.
Subdivision Section Block 'Lot•
Other Property Identification t VICIP rTlf- /�S 'arc. / .1-- ..
_.___. /D ension/size of Lot/Property S'7. �/ /�C t 4 .
Other Application Information '+..
t
I Building/facility New ✓Existing .
. Interrnitient Use'••,_ - ' Yes No If yes,describe..--
i
II. Residential Use 'N ✓Yes No
r • I Termite Treatment • t,'"Yes • No
•. ✓ Single Family Multi-family •
• (Number of Bedrooms } (Number of Units. ) •
' . Basement Yes ✓No
Fixtures in Basement Yes ✓No
- III. Commerical Use Yes __ No - Describe:
Commerical/Wastewater Yes —Na a Number of Patrons •
/ II,�,�Number of Employees•I ' .�
If yes, give volumes and describe 1 A�� t//•'f r ' -' ' ' f �`-. /
7 / 1 / 1 7 1 t I / r a, D6
• - • / /♦ - - r / 1•
, /
•
IV. Water Supply: Public •. New ' Existing
Private V New Existing
Describe:
• V. Proposed Sewage Disposal Method:
. Onsite»Sewage"D p'1-Systern• aepiic-Tank13rainfleld ---LED—__. _Me
Pubtic`Sewerage System ' ,/
•
Attach a site plan(rough sketch) showing dimensions of property,proposed and/or existing structures and
4 driveways, underground utilities, adjacent soil absorption system,bodies of water,drainage ways,and wells and :
r d• 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 narked and the property is sufficiently visible to see the topography.
. I give permission toto the De `rtiment to enter onto the property described for the purpose of processing this application.
G / ,r • • -v. -5-g-6 a - — -
. ! Signature of Owner/Agent , Date -+, •
/ -
. PT. D
PT A 550°46'41"E 55.59
w S 13°49 40'E 180.46
)9°34'11"E 157.06 S 04°42'46"W 63 71
1!°45'0812'32"E 59.3411 Deborah Ann Dempsey S 15°3T.27"W 63.80
19°f2'24'�W 164.11 S 07038 56 E 119.24
'9°21'24"W 164.67 D.B. 79f ' 72
D.
6°13.08"W 167.00 B 741 - 736 Plot PT. C
'0°34'28"W 51 08 PT D
'6°O4'l9''W 138 00 Lib' `\0
3°10'26"W 138.75 ° 1\\
9°36'S8"w 32.95 ....------.--------------1 1 0.42 s' e %
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13°2B'47�"W 66.96 �69 Well ret Ira NR.o.Woy N a,'`3
f0°09'18 W 180 97 X ° 1 Story Fro + _..Sl� °fff .iron Set 'Leo ` r ?°
9°12'�56"W 49.96 Frame 8v d• 7 . ° 1 '�a 7
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)4°52 27"E 47.00 / 1 I Sir. N a'°
2°06.03"E 242.39 75 :it'd:•. 1 ij_ VA
)7°21'16"W 47.90 Line PT. C 1 1+ HTt°I1 37,.EPi ,
PT. C j ! 00 0 ,?3.4,
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Sfr. 1.5 qt p��\`\` Eemr.
Gertrude M. Lewis b Sp ��
D.B. N,N
522 - 399 qQ
D.B. 296 - 277Plot �1
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PARCEL A-I %
57.41 AC. ‘�\\
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( O• .B. 741 - 736 Plot \ o
i i Ernest B. B 11 v Co-°D io
1I Belly J. Dome►on v , A it.
1 O.B. 708= 4 41 \ '71w 3
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1 0 h 0.8. 697- 128 / a , a
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• D.B. 290 - 278 PT. A
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1 PT. A N•‘'.
'08'58"W 46.12 `�\\ Exislln •
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*05''34 34"E 4"W 6.6.090 \ 1 Private A etas NOTES: -
OS
•O40.41"E 262.60 I r Esmt. •
°S3'O4"E 112.00 j r D.B. 741 - 726 I THIS PROPERTY DOES NOT LIE WITHIN THE '
°20'16"E 104.85 r 1 100 YEAR FLOOD PLAIN ACCORDING TO THE
°47'04"E 4 4.65 1 f FLOOD INSURANCE RATE MAPS
°40'04"E 36.50 / J 2. TELEPHONE LINES IN THIS AREA ARE
*51 14'�E 52.45 // UNDERGROUND.
°45.20 E 65.46 /
1°03'49"E 25.56 1 1 3. • DENOTES IRON FOUND.
i°52'04"E 70.00 11 '
°30'27"E 31.42 1 PT. 8
1°13'04"E 133.00 1��1 e
'O57'25"E 42.81 sT. ` .�
i°I2'04"E 103.60 . RT. Toe
i°38'55"E 37.13 •
123 'E 52.0
° PHYSICAL SURVEY
° 12.39"E 52.07 •I° 14'37"E 57.34
a°-48=34"E-7-:-:62..40-7-:--- -- 74.-4.:...;.-w-•-=- - - _.._. __ .QF--P-ARCFa:.__A_1•------ _ - - -• - --
SO/age Disposal System Operation Permit
Commonwealth of Virginia r.
Department of Health Health Department
Identification No. CT)-11n-C %glop'
Tax Map No. 115-5-53 , Thomas Jefferson Health Department
Deborah Ann Demasev is Hereby Granted Perms;
• to Operate a (Type) I Sewage Disposal System Having a Design Capacity of_ _ ion gpd, at
end of Private Road 1.5 miles North of Roan 70R namr WnnAriAna •
SUBDIVISION SECTION/BLOCK LOT
NA NA MR
This permit is Issued in Accordance with the Provisions of 32.1, Chapter 6 of the Code of Virginia as Amended and Section(s)
3.22 of the Sewage Handling and Disposal Regulations of the Virginia Department of Health,and
with Previously Issued permits ill
Dated
with the understanding that the Owner and/or any Subsequent Owner will operate the Sewage Disposal System in Accorda^"..
with the Sewage Handling and Disposal Regulations of the Virginia Department of Health and any Variances or Conditions Gran'
Issuance of an Operating Permit does not imply or Guarantee that the Sewage Disposal System will Function for any Specified
Period of Time. .
VARIANCES GRANTED SPECIAL•CONDITIONS
Q; NONE 0 SEE ATTACHED E1 NONE E1 SEE ATTACHEDor-
Effective Date Recommended(Sanitarian) Approved (State Health Commissioner)
C.H.S. 205 Rev. 4/B3
completion Statement . . . . .
Commonwealth of Virginia ,
State Department of Health Health Department .
, Identification Numbers "e-i-- 6 •
• _ 0,f277K� ,Ali§9 Health Departm€ .
• Name of -Company/Corporation/Individual: ' . -",:.> # �./k :X II,15/2R •
Address: /�t"‹r?/i//.C_ /
4'_ • Telephone: , -•. . .
Owner's Name `/). .4 A 4'z12 Z 'iflXd _ . .
Owners Address - • a5e G3 / ' be`y?/rr». - 72Q�. 2
• Location of Installation: , Lot A%A . • ••- - . • - ' Block •41 • - - - - .. .
•
Section:. . . Ard •• ' ' Subdivision: . �.a- - . -
Other: / /27.1/P .3 A/ A 7a' /240, .. j i - /�i r*A. • '
/1 hereby certify that the onsite sewage disposal•system has been installed and completed'in accordance' with the con-
struction ,permit issued (date). _/1/? ,!q' .94 - • and is in compliance with Part D of the Sewage
.Handling and Disposal :Regulations and when appropriate the• plans and specifications for•the'project. .
t/ / -4' - . rra--xne,, . f t ton s-A
Date .
Signature and Title
.
C.H.S. 203 Rev. 4/83
l
!,a ,.
(.±: .-. — - Q vo 0 . eve . 1
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11
Sewage Disposal ►stem Construction P mit PAGE i OF.... —
Commonwealth of Virginia Health Department -64-6
. D artment of ealth : . m Identification Number
e7'�4 �o/sg72 Health Department Map Reference �2S: — 33
General Information
/
New ki Repair 0 Expanded 0 Conditional 0 FHA ❑ VA 0 Case No.
Based on the application for a sewage disposal system construction permit filed in accordance with Section
3.13.01, a constructio •per it is bareby issued to:
' Owner ''� Tel ph ng, 9 a6*
Address P U- ' Y :Fa ` A7e. , Ai, 2 Z •�c�J , r) i
For a Type Sewage disposal system which is to be constructed onLat &'/�d € r////47f
oor /1 /ll//'�S /i 'M ifD /3 "!Gyt.17/doe
Subdivision �`� Secf n .Blo 1 At/ - _ . _. _ Lot ��
Actual or estimated water use _0� Wrl�
•
DESIGN - / NOTE: INSPECTION RESULTS
Water supply, existing: (describe) Water supply location: yes g no 0 comments
//ed iPfi Satisfactory
To be Installed:class
cased grouted -
I , Building sewer: Building sewer: yes ID no p comments
!' I.D. PVC 40, or equivalent. Satisfactory
Slope 1.25" per 10' (minimum).
O Other
Septic tank: Capacity _7 ' gals. (minimum). Pretreatment unit: • yes iEl no ❑ comments
' ❑ Other Satisfactory
Inlet-outlet structure: Inlet-outlet structure: yes Z no 0 comments
PVC 40,4" tees or equivalent. Satisfactory
❑ Other •
•
Pump fond pump station: Pump&pump station: yes ❑ no 0(comments
No*] Yes 0 describe and shown design. Satisfactory /7d�4941/1
• if yes: 4// _
Gravity mains: ,3" or larger I.D., minimum 6" fall per Conveyance method: yes iZr no ❑ comments
100', 1500 lb. crush strength or equivalent. Satisfactory
❑ Other -
Distribution box: Distribution box: yes g/ no 0 comments
Precast concrete with /d ports. Satisfactory
• ❑ Other
Header lines: Header"lines: yes,t 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. '
Cther
Percolation lines: Percolation Ines: yes no 0 comments
Gravity 4" plastic 1000 lb. per foot bearing load or Satisfactory _
equivalent, slope 2" 4" (min. max.) per 100'.
❑ Other '
Absorption trenches: Absorption trenches: yes d no 0 comments
Square ft. required �t2 : depth from ground/surface Satisfactory
to bottom of trench ; aggregate size'—/if -: /, •'`>,
Trench bottom slope 2 •//4,7 /a,4e;i f1 / /(i I/
center to center spacing ; trench width 3G Date C% 2 I 1 Arms/pected and approved,by:
Sanitarian
C.H.S.202A Revised 4/83
Health lartment ��¢_ .
'.O.. i. Identifi„o .r. n Number _..
• 'Schematic drawing•of sewage.disposal system-and topographic features: . -"PAGE • • '":OFF
• •Show the lot lines of thetbuilding lot and building site, sketch of.property showing any topographic features which may impact.on the design.of
the system,'•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.
....•.IThe information required above,has.been-drawn on-the attached copy-of,the••sketch submitted-with'the.application. -•J
Attach additional sheets as necessary•to•illustrate.the design.' '
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The sewage disposal system is to be constructed as specified-by the permit Vfor attached plans and specifications ❑.
This sewage disposal system construction permit is null and void if (a) conditions are changed from those shown on the application (b) condi-
tions are changed from those shown on the construction permit. If construction has not commenced within 12 months'of date of issuance, the
construction permit must be revalidated.
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-in tailation which has been covered "prior to approval shall be uncov-
ered,If necessary,upon the direction of the Department. /�
Date: r j geed Issued by: ��1 r r,l/ // -
��l )11,-- o
Date: 4 - 4- Reviewed by: \ - _� ��_M��
ISupervisory Sanitarian
�.__r/.-
If FHA or VA financing .
Reviewed by Date Date
Supervisory Sanitarian Regional Sanitarian
C.H.S.2028 Revised 4/83
Application for a`'.:Jwage Disposal S,ystt... Construction Permit
. Commonwealth of Virginia For Department Use Only • Health Department . ��—8' ., '
Department of Health Identification_Number
. Map Reference /lam" 5- — .-5 ,
•
•
.71ai Health Department , Date Received c4n / /-9814
To Be Completed By The Applicant
- Type sewage system: _ New 0 Repair 0 Expanded ❑ Conditional
•
-� 1F_HA/VA yes ❑ no ❑ /
Owner ve � ) cc \ R'v.v,-0)2,'M�5f,y Address rib..�X 3b • Phone 97 I' 64_. ,
r ` I `Fr-e-{, tA4Njo�,kf y,aI5`/0 Wo 3- 1V
Agent Address • Phone _
` ‘, lAw to
t n 4c
Directions to Property, lb S T1b 53 tb A16Kii•t.e-llb "1vA rv% K� L4- 7 1J eA to
r i k k 49 a.° —7 M I r..5 `6 --1 0$ vor+n R. • -a-A est eqx-.Lokt.
Subdivision •-• Section • - Block - • Lot
Other Property Identification " •
Dimensions/size-of-Lot/P 57 0‘0 4r•GS • • •
Other Application Information • '
•
1: Building/faculty - ❑ New • Existing ' ' •
. ' Intermittent Use ❑ Yes 0 .No• If yes, describe: - :• •
•
•
Ii. Residential Use • [1Yes ❑•No .
Termite Treatment • 0 Yes .0 No •
[Single Family O. Multifamily Number of Units — Number of Bedrooms -
Basement • _ 0 Yes ' . ' is,No •
Fixtures in Basement ❑ Yes • ❑•No • ,
• IiI. 'Commercial Use i ❑ Yes ' 0 No ' Describe: , • - .
Commercial/Wastewater ❑•Yes ; 0 No Number of Patrons Number of Employees.
If yes, give volumes and describe - - .
iV. Water Supply: 0 Public 0 New , Describe: W -e_ 11 . • • .
• ❑ Private fs Existing • -
V. •Proposed Installation: • gl 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 and 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
• t 's app'catipn, n 1A'
`�s• //1111�� �A� at i 1 V
Signature f ownIt Date
.
•
• C.H.S.200 Revised 4/03' . .
_�=. ._ .: . - - 1
• Application for a ��wage Disposal Syste... •Construction Permit
Commonwealth of Virginia For Department Use Only ' Health Department
Department of Health Identification Number ' --844 6
• Map Reference //S— .5- - 55
•
7,yy i- h177Health Department Date Received C422 9 /9<94
• • To Be Completed By The Applicant. .
Type sewage system: ❑Q New . 0 Repair 0 Expanded ❑ Conditional
\FHA/VA yes 0 no 0
Owner T)P �-7nr4.-.1,‘ A v.v-, l )e,,nn QS{.\/ Address -RN cSX'Jb Phone 9711- 6al(o e ��. Lt'r Iov\ tic., (��� /O w 3`1-1 OVP
Agent Address • Phone
. �5� LAW in
• S
{{ � t �
Directions to Property '. b S '1 b. 5 3 'fo• N1 b k—1 c e_ b. f t"IrvN (K c -7 619 9 o+in0,11
\.,-�-1-- to aO - r li_S -it, ? T ry R; c. - -aJ dQ , ioet3c,r
v
Subdivision Section - • .Block. • Lot
Other Property-.Identification • .
-Dimensions/size of- Lot/Property /5 a\o J• - S .
Other Application Information -
• I. Buildin /fac111New ./Existin -• . • •
9 tY 0 ❑ 9 .
Intermittent Use • 0 Yes • - ❑ No If yes, describe:
II. Residential 'Use jjYes ❑ No -
Termite Treatment 0 Yes ❑ No
' .p"Single Family ❑ Multifamily Number of.Units — -Number of.Bedrooms
Basement •❑ Yes .•' pNNo .
Fixtures In Basement 0 Yes • r`' , . 0 No -
• Ill. .Commercial Use ❑ Yes 0 No Describe:
• Commercial/Wastewater 0 Yes 0 No Number of Patrons Number of Employees
If yes, give volumes and describe .
IV: Water Supply: , ❑ Public - ❑' New Describe: } .e-,\
0 Private a Existing -
V. Proposed installation: (Si Septic tank and drainfield 0 Other , •
1f 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 and 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.
I. S..i.lort )\•,‘ (NA_ ...c. A APAAW-4.11 1
, 1 al" Cil Paq
Signature of ownerLegent ._ v Date '
C.M.S.200 Rerbed 4/E3 I
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Soil Evaluation Fe__A
PAGE / of•
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Commonwealth of Virginia. Health Department �r
Department of Health Identification Number .. `81—G
Tax Map Number ll.$ —.1-° 5-
• General Information �/ •
Dat �7AA` S j P`/.—?rJ?iT Health Department
Applicant c�-23D f4/ "k/) 205/ Telephone No. 977
Address A'e• 'B 'iBLl/J/B7)3O Ti fi. 22Y4o �O/'� 973-764
Owner Address -5/.'me
• Location .�.�/"/A/ 4 �a % jt 7Oc9 �l ai' /'/,#f('it2//c)
Subdivision /1/.4 Block/Section A4 Lot /1*
Soil Information Summary
1. Position In landscape satisfactory Yes O No ❑ Descri G SC e
2. Slope . _ % "
1.
3. Depth to rock/impervious strata Max. Min.6 None
4. Depth to seasonal water table (gray mottling or gray color) No id Yes 0 inches
5. Free water present No W Yes D. _ range in inches
6. Soil percolation rate estimated Yes Texture group I• II IV .
_ No 0 Estimated rate Sa min/ inch
- 7. Percolation test performed • Yes ❑ Number of percolation test holes/4fi4
No pr. Depth of percolation test holes 4 -
Avera e per lationlr to //f
Name and title of ev /r':
Signature:
• Department Use
[Site Approved: Drainfield to be placed at -51 q depth at site designated on permit.
❑ Site Disapproved:
Reasons for rejection: •
1. 0 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. 0 Insufficient area of acceptable soil for required drainfield,and/or Reserve Area.
6. 0 Proposed system too close to well.
7. ❑- Other.Specify
C.H.S.201A Revised 4/03
• pate of Evaluation�`7! —� Profile Description `Health Department , _ ^r
SOIL EVALUATION REPORT Identification No. �O
Page •2- of 2-
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 pro-
. tile 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.
0 See application sketch 1 construction permit 0 See sketch on reverse side or
- • page attached to this form. -
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- Remarks: %j� �e.�9�04 /mac/ /12 C A571-?3
_ Z(p,5 qg,‘e )
C.H.S.2018 Revised 4/83 . . -
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TAG SHEET
Permit I.D.#: i Owner: I77ra. ,
•
• Agent: San&a ki ne
Tax Map #• 115 3
• Subdivision: Lot:
{} Combination Permit 0 Repair Permit 0 Septic Permit )(Well Permit
0 Well Abandonment 0 Certification Letter
DATE r INITIALS
Application Received
/ fs' -Assigned To: ��/�,�
AOSE Submittal • *Yes )(No
16qJ .ur), 0-2
Site Visit Scheduled 8(1'
f
Time: // 3O / OO
. Comments:
Site Visit Rescheduled
Time:
Site Visit Made '/ i
�'
Date Given to OSS 3 /7/g<-
Data Entry
Construction Permit 0 Issued {} Denied
Certification Letter $ Issued {} Denied
Survey Received 0 Yes $ No
Construction Permit Mailed.
Construction Permit Picked-Up
Septic Maintenance
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