HomeMy WebLinkAboutSDP202100017 Other 2021-07-27OSETE Inspection Report and Completion Statement
Commonwealth of Virginia
State Department of Health
Health Department Identification Number: 101-16-0162 Tax Map:
Albemarle County
Name of OSE/PE: Michael F Craun
Address: 2036 Forest Drive Waynesboro, VA 22980
Contractors Name Christians and Associates
Owner's Name: Virginia Asphalt Services (C/O Bryan Heilman)
Owner's Address: 439 Burchs Creek Road Crozet, VA 22932
Location of Installation: Subdivision:
n.h,... 1536 Avon Street Extended Charlottesville, VA
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Section:
540-942-5600
Block:
77-8
_ Health Department
036859
Lot:
Component
Comments, Materials, Etc.
Deficiencies Observed, Date Deficiencies Observed
Corrective Action Required
Date Approved
Water Supply Location and
Construction
Public
N/A
Building Sewer
4" SCH 40 PVC
5/26/16
Septic Tank
New - 1000 Gallon Top Seam Plastic - Infiltrator
5126/16
Inlet -Outlet Structure
Inlet - 4" SCH 40 Sanitary Tee
Outlet - Zabel A300 12x20-VC-Ball
5/26/16
Pump and Pump Station
N/A
Conveyance Method
4" SCH 40 PVC
5/26116
Distribution Box or
Pressure Manifold
D Box Concrete #12
5126116
Header, Conveyance,
Return, etc. Lines
4" PVC
5/26116
Percolation Lines, Drip,
Chambers, etc.
Percolation Lines - EZ Flow, 3' Wide, 50 feet long, 42" deep
5126116
Absorption Trenches and
Dispersal Field
Trenches - 2 Laterals - 9' On center - 300 sqft
5126/16
(Other Components:
treatment unit, etc.)
Treatment 1 - AS500 EZ Top
12/8116
Treatment 2 - UV Disinfection
12/8/16
Attach observed deficiencies and corrective actions taken on a separate completion statement as necessary.
This form contains personal information subject to disclosure under the Freedom of Information Act. Revised 12/1/2014
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OSETE Completion Statement: As -Built Drawing
Commomvealtlt of V;rainia
State Department of Ifealth
Health Department Identification Number: 101-16-0162
Triangulate critical system components to fixed reference points
Tax Ma 77-8
I Z
A
❑ Check here if as-buitt drawing is on a separate page attached to this form
(Attachment must display Health Dept. Identification Number, tax map number, and must be signed and dated by AOSETE).
I hereby certify that on � l a1 YLJ9 36 (date), I, or an employee under my direct supervision, inspected this sewage system's
construction. The onsite sewage 'system ash been installed and completed in accordance with the construction permit issued on
6/2/16 _ __ (date) and is in compliance with the .Sewage Handling and Disposal Regulations (12 VAC 5-610 et
sect, the Regulations for AhMhl re )r ite Sewage Systems (12VAC5-613 et seq), when applicable, the Private Well Regulations (12 VAC
5-630 et seq), when applicable, d t ans and specifications for the project %� %�
OSE/PE Signature:_._.. 1 _ __Date: r2-A
Print Name: Michael Craun
This form contains personal information subject to disclosure under the Freedom of Information Act. Revised 12/t/2014
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