HomeMy WebLinkAboutSUB202300009 Plat - Submittal (First) 2023-01-131 �1
COMMONWEALTH OF VIRGINIA
VIRGINIA DEPARTMENT OF HEALTH
Albemarle County Health Department
PO Box 7546
..Charlottesville, VA 22906
(434)972-6259
SEWAGE DISPOSAL SYSTEM OPERATION PERMIT
Tax Map No.: 8-166
Type of Property: Residential
Health Dept. Id. 101-06-0277
Building Permit # 95-538 SF
McRaven, Charles & Linda, P.O. Box G, Free Union, VA 22940 (434) 973-4859, is Hereby
Granted Permission to Operate a Type I Sewage System, Having Design Capacity of 450
gallons per day, and 3 Bedrooms at 814 Davis Shop Road, Free Union, VA 22940
Subdivision Section Lot
This Permit is Issued in Accordance with the Provisions of Title 32.1, Chapter 6 of the Code of
Virginia as Amended and Section(s) 12-VAC5-610-340 of Sewage Handling Disposal
Regulations of Virginia Department of Health and permit dated May 15, 2006.
April 11, 2007 Travis Davis ✓�f.> w� �/ �o`;
Effective Date EHS Approved
COMMONWEALTH OF VIRGINIA
VIRGINIA DEPARTMENT OF HEALTH
Albemarle County Health Department
PO Box 7546
Charlottesville, VA 22906
(434) 972-6259
PRIVATE WELL SYSTEM OPERATION PERMIT
Tax Map No.: 8-16B
Health Dept. Id. 101-06-0277 Building Permit # 95-538 SF
McRaven, Charles & Linda, P.O. Box G, Free Union, VA 22940 (434) 973-4859, is Hereby
Granted Permission to Operate a Class IIIC Well, located at 814 Davis Shop Road , Free
Union, VA 2294b
Subdivision . Section Lot
This Permit is Issued in Accordance with the Provisions of Title 32.1, Chapter 6 of the Code of
Virginia as Amended and Section(s) 12-VAC5-630-330 of Private Well Regulations of the
Virginia Department of Health and permit dated May 15, 2006
April 11, 2007 Travis Davis _ /ifat�tC ✓.
Effective Date EHS Approved
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VDHSPAR IA Albemarle County Health Department
DEPARTMENT PO Box 7546
OF HEALTH Charlottesville, VA 22906
(434) 972-6259 Voice
Protecting You and Your Environment (434) 972-6221 Fax '
June 12, 2006
McRaven, Charles &Linda
P.O. Box C 10'2 1�61' i'O v is Shop \2c1
Free Union, VA 22940
Frei I.iv\;o� � V a, 9a'4 0,
RE: Items Needed for Final Completion - Health Department ID # 101-06-0277
Tax Map #: 8-16B
Dear McRaven, Charles & Linda:
A review of our records show that we are missing important information about.your sewage
disposal system and/or water supply system. While this information is important to us, it should be even
more important to you. In particular, we are missing the following checked items:
Sewage Dftosal System
X Co p> bn Statement- to be filled out completely and signed by septic contractor.
AOSECompletion Statement and inspection Report- to be completed by the AOSE who
inspected and approved sewage disposal system installation.
Engineer Completion Statement and Inspection Report- to be completed by the the
engineer inespenl and approved installation of sewage disposal system.
33MM 66 rr
XlVorlce of Substitution Form- to be filled out completely and signed by septic contractor
and own o propJgLt� 0q
s--Built"Drawing- to be completed by owner or contractor. Distribution box must be
Water Supply System
ZZSampleAnalysis-
Well Completion Report -to be completed by well driller.
��O
X to be tested by a state approved lab. You can obtain a list of
state approved labs in the area by contacting the Health Department or our website at
ww. vdh. virginia.gov/LHDltj/env_services.asp
m
Other Items Needed
X Physica/Address- 911 address of property.
WeII Inspection- The well inspection is an inspection that is performed by the Health
Department once the well has been completed. The purpose of this inspection is to insure that the well
has been drilled in the permitted well area, has the proper amount of casing and grout, and has an
approved well cap.
Pump Inspection- Health Department must observe the pump's drawdown. To schedule
a same -day pump inspection, contractor must call the Health Department before 9:00 a.m. the day of
inspection. Pump chamber must be filled with water to the level at which the floats will activate pump
drawdown.
Before the Health Department can approve your sewage disposal and water supply systems for
operation, the appropriate documents must be submitted.and all inspections completed. Should you have
any questions about this letter or the information we need to complete your file, please feel free to contact
our office.
Sincerely,
...
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Completion Statement
Commonwealth of Virginia
State Department of Health
FEB E 7 2007
Name of Company/Corporation/Individual:
Y-/6.h
Health Department
Identification Number 1 OI - QED -C)Z_1%
AIF,e-moxIP_ Health Department
Address:
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br Telephone: Cy3y J 9'8S - )Z.00f
Owner's
Name Cbades
d- Z tn(}O. Mckayen
' Owner's Address P.O. C30X G Free Onion VA ZZ140
Location of Installation: Lot Block
Section: Subdivision:
Other:4814 hoo RA
I hereby certify that the onsite sewage disposal system has been installed and completed in accordance with the con-
struction permit issued (date) S- 1.5 - ( L0 and is in compliance with Part D of the Sewage
Handling and Disposal Regulations and when appropriate the plans and specifications for the project.
7—/2�i/%�ilitfi
Date Ignature and Title
C.H.S. 203 .Rev. 4/69 -
v-S0-�-DO-:C-)i
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WARRANTY, NOTICE OF SUBSTITUTION and WAIVER OF LIABILITY
RECEIVED
County/Cityof Albemac le,
Sewage Disposal System Construction Permit ID # 1 O 1- OLo - O 2 -11 Tax Map # 8 ' 1 to bFEB 2 7 707
Cproperty description:
Owner: Chaflea * ia Mc Raven Date: 5-15-Ob ENNI ONAI TALNECH
.LIMITED FIVE YEAR WARRANTY
a) Ring Industrial Group, EZflow warrants that the EZfIowT EPS Aggregate System manufactured by Ring Industrial Group, EZflow, when installed and operated
in accordance with the manufacturer's instructions and the current Virginia Department of Health GMP 116, Use of Gravelless Systems Manufacturer's Specifications,
and pursuant to all necessary building permits, are warranted for a period of five (5) years from the date of installation (i) to be free from defective materials and
workmanship; and (ii) to perform in accordance with the state performance requirements in effect on the date of installation. This warranty extends only to the property
owner. For purposes of this warranty, the EZf/owTM EPS Aggregate System must be installed in accordance with all site conditions specified in the Local Health
Department Construction Permit and sized according to the Company's specification.
b) System failures determined to be due to improper siting, excessive water usage, improper grease disposal, improper installation, improper operation, or improper
maintenance are not part of this warranty.
Upon notification of a system failure, the Company may, at its option, perform or have performed certain tests to determine the cause of failure. A registered soil
scientist or professional engineer may be used to evaluate the soil conditions and compare those conditions with any original evaluation, which may appear on the
permit.
—In�order-to.exercise�these-waranty-rights, the•property-ownermusbnotify-the Company-in-writing-ar,its:corpomteLheadquarter-within-15 days -of discovery ofthe
alleged defect. The notice shall be accompanied by (i) a copy of the warranty which is signed and dated by the installer and the property owner as set forth below; (n) a
copy of the appropriate permit for the septic system; and (in) proof to the Company's satisfaction that the septic tank has been maintained in accordance with the
Company's operating instructions. In the event of breach of warranty due to s failure of the trench, the Company will provide and install EZf/owTM EPS Aggregate
System units as necessary to extend the size of the trench to provide a fully functional wastewater system. The Company will not be responsible for pumps and any
other necessary mechanical devices needed to extend the trench.
c) THE WARRANTY IN SUBPARAGRAPH (a) AND THE REMEDIES IN SUBPARAGRAPH (b) ARE EXCLUSIVE. THERE ARE NO OTHER WARRANTIES.
ANY IMPLIED WARRANTIES OF MERCHANTABILITY AND OF FITNESS FOR A PARTICULAR PURPOSE SHALL NOT EXTEND BEYOND THE
PERIOD IN SUBPARAGRAPH (a). THE WARRANTY DOES NOT EXTEND TO INCIDENTAL, CONSEQUENTIAL, SPECIAL, OR INDIRECT DAMAGES.
THE COMPANY SHALL NOT BE LIABLE FOR PENALTIES OR LIQUIDATED DAMAGES, LOSS OF PRODUCTION AND PROFITS, LABOR AND
MATERIALS, OVERHEAD COSTS, OR OTHER LOSS OR EXPENSE. SPECIFICALLY EXCLUDED ARE DAMAGE DUE TO ORDINARY WEAR AND
TEAR, ALTERATION, ACCIDENT, MISUSE, ABUSE, OR NEGLECT; THE UNITS BEING SUBJECTED TO STRESSES OR VEHICLE TRAFFIC GREATER
THAN THOSE PRESCRIBED IN THE INSTALLATION INSTRUCTIONS OR OPERATION INSTRUCTIONS; FAILURE TO MAINTAIN THE MINIMUM
GROUND COVERS SET FORTH IN THE OPERATION INSTRUCTIONS; THE PLACEMENT OF IMPROPER MATERIALS INTO THE SYSTEM; OR ANY
OTHER EVENT NOT CAUSED BY THE COMPANY. THIS WARRANTY SHALL BE VOID IF THE PROPERTY OWNER FAILS TO COMPLY WITH ALL OF
THE TERMS SET FORTH IN SUBPARAGRAPH (b).
FURTHERMORE, IN NO EVENT SHALL THE COMPANY BE RESPONSIBLE FOR ANY LOSS OR DAMAGE TO THE PROPERTY OWNER, THE UNITS,
OR ANY THIRD PARTY RESULTING FROM THE INSTALLATION OR SHIPMENT OF THE UNITS, OR FROM ANY PRODUCT LIABILITY CLAIMS OF
THE ORIGINAL PROPERTY OWNER OR ANY THIRD PARTY. THE COMPANY SHALL NOT BE RESPONSIBLE FOR ENSURING THAT INSTALLATION
OF THE SYSTEM IS COMPLETED IN ACCORDANCE WITH ALL APPLICABLE LAWS, CODES, RULES, AND REGULATIONS.
d) No representative of the Company has the authority to change this warranty in any manner whatsoever, or to extend this warranty. No warranty applies to any party
other than to the property owner. -
NOTICE OF SUBSTITUTION
— - - (WHERE-AN-AOSEOR-PE SPECIFIES -A SUBSTITUTED SYSTEM)- -
This is to notify the Virginia Department of Health ("VDH") that a EZfIowT EPS Aggregate System - Model EZ , ("Substituted System") Will be substituted
for a gravel- type drainfield system.
I understand that the Substituted System is not the system that would be designed by the M1Jerriad County/City Health Department. The Substituted System, however,
is authorized for use in the Commonwealth of Virginia pursuant to VDH's Guidance Memoranda and Policy (GMP) #116. I further understand that the Substituted System is
covered by a manufacturer's warranty and that such a warranty is not available for the system that would be prescribed by VDH.
1 understand that, regardless of whether the Substituted System or the gravel -type dminfreld system is installed, the Commonwealth of Virginia requires that the owner
maintain and preserve the entire approved absorption area (including reserve area where applicable) that was required by the permit. This condition is intended to assure that
any absorption area that is not used will be available in the future should it become necessary to repair or replace the System. I hereby agree that 1 will maintain and preserve
the entire absorption area as required.
WAIVER
As OWNER of the property described above and subject to the exception described below, I hereby release and agree to hold harmless the Virginia Department of Health and
the Commonwealth of Virginia, including, without limitation, any and all of its agencies, boards, and commissions, their insurer(s), officers, directors, employees,
representatives, and agents [hereafter referred to as the "COMMONWEALTH OF VIRGINIA"], from any and all claims, complaints, demands, actions, causes of action,
liabilities and obligations, of whatever source or nature, whether administrative, legal or equitable, whether known or unknown, which the OWNER now has or has in the
future relating to or arising out of the installation of the Substituted System including, without limitation, any and all claims due to the failure of any person to comply with
federal, state, or local laws or regulations, claims under the Virginia Ton Claims Act, the Virginia Constitution, the United States Constitution and amendments thereto, or
under common law.
I understand that the COMMONWEALTH OF VIRGINIA does not warrant in any way the performance of any System and that the manufacturer's warranty is the sole
remedy available to me with respect to any performance deficiency associated with a Substituted System. Furthermore, 1 agree to first seek and exhaust any and all remedies
under the manufacturer's warranty before applying for indemnification under the Onsite Sewage Indemnification Fund.
EXCEPTION- Onsite Sewage Indemnification Fund: I do not release the COMMONWEALTH OF VIRGINIA from any liabilities, claims, or causes of action provided
under§32.1=164.1:0f of the Code of -Virginia (Onsim Sewage lndemnification-Fund)..I.acknowledgeand affirtn,that the Onsite.Sewage.lndemnification Fund shall be the
sole remedy for failure of the Substituted System where such failure results from negligence on the part of VDH. I also acknowledge and affirm that tree Virginia Department "
of Health's authorization of the Substituted System pursuant to GMP #116 shall not constitute an act of negligence pursuant to §32.1-164.1:01 of the Code of Virginia.
This agreement shall be binding upon all subsequent owners of this property including any and all HEIRS, SUCCESSORS, and ASSIGNS.
ACKNOWLEDGEMENT
I acknowledge that I have read this WARRANTY, NOTICE OF SUBSTITUTION, and WAIVER and that lunderstand their terms. I also understand that there is no
warranty if I do not comply with all of the above steps or if the system is not installed or maintained properly. I acknowledge to the Company that this warranty is part of my
original agreement to purchase the septic system and that the warranty and its limitations were provided to me at the time of purchase.
514 llcavis Lt Ra
Address of Installation (Street)
Free— Union vA Z2940
(City)
(Subdivision Name) (Lot #)
Clacxrles a- Lin6c, MCRcven
lame (print) and Address of Property Owner
P.O. c C JA Zt9 �0
perry Owner Signature Date �f�/��
I acknowledge to the Company and the homeowner that the septic system and the EZflowTM EPS Aggregate System units have been installed in accordance with GMP 116,
�((he installation instructions of the Company and in accordance with all state trench requirements and other applicable laws.
LSnil*e Cxrccklccbr) le av' ne 6c,1 Glee -I
Busine s Name of Installer Name (p ini t)
(Street/P.O. Box)
(Phone) Signature Date
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Approved Virginia EZflow Models
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1203H 1203T -twuZn
NOTES:
A. Linear footage (LF) of EZffow EPS Aggregate is based on current Virginia Dept. of Health (VDH) loading rates per
VAC 5-610-950 and the following Manufactaurer's Sizing equivalencies (based on soil interface area).
1203T = 50.0 sf/10' EPS bundle or 25.0 sf/5' EPS bundle (5.00 sf/ft.); 1203H = 50.0 sf/10' EPS bundle or 25.0 sf/5'
EPS bundle (5.00 sf/ft); 1402H = 42.9 sf/10' EPS bundle or 21.45 sf/5' EPS bundle (4.29 sf/ft);
B. Minimum EPS Aggregate footprint required for any system is 300 sf. (120 If ofl203T 100 If of 1203H; 130 If of 1402H)
C. The minimum lineal footage of EPS Aggregate shall be calculated based on a minimum of 2 bedrooms.
D. All substituted systems shall be installed with the same footprint required for a conventional gravel system.
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65 Industrial Park • 0alkland, Ten -lessee 380110-4133 • 901-495-63330 Fax 901-405-1181
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Charles 8t Linda McRaven
P.O. Box 108
Free Union, VA 22940
434-973-4859 fax 973-3503
mcraven20mindspring.com www.chariesmcraven.com
26 February 2007
Septic Permit Department
Thomas Jefferson Health District
1 138 Rose Hill Drive
Charlottesville, VA 22902
RE: • .Permit,ID #, 101;06-0277
Ladies 8t Gentlemen:
Enclosed are the completion papers for the septic system placed at our new structure at
1814 Davis Shop Road.
Please notice that the address on the Permit is 814 Davis Shop Road. This address is
incorrect. The correct address of the Work performed is 1814 Davis Shop Road. Please make this
change on your permit and in your files. We have not corrected the documents being submitted,
preferring them to match your existing nomenclature, and allowing you the opportunity to make all
changes at the same time.
Thank you for your attention to this change.
Sincerely yours,
Linda M. cRaven
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'CAME TO SEE YOU
WILL CALL AGAIN
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Albemarle County Health Department
Sewage Disposal System & Water Supply Construction Inspection
Owner: McRaven, Charles & Linda
Owner Phone: (434) 973-4859
P.O. BOX G
Health Dept. ID: 101-06-0277
Free Union VA 22940
Tax Map Number: 8-16B
Subdivision: Section: Lot:
Property Address:
EHS: For each item, circle status. date and sign
Sewer line:
Satisfactory: ' e_s/
Pending - incomplete
Pending -- needs correction
Comments: G� Uo
Septic Tank:
Satisfactory:
•Pending - incomplete
Pending -- needs correction
Comments:
1000 ",
Inlet/Outlet Structure
Satisfactory: Yes �.
Pending - incomplete
Pending -- needs correction
Comments:
Pump System:
-�
Sat1kfacXwia I Y s
Pe n t
ending - e orr ction
Comments:
Conveyance Line/Force Main'
Satisfactory: Y ;r"c� V
Pending - incomplete
Pending -- needs correction
Comments:
Distribution Box/Distribution System '
Satisfactory: Yea
.Pending - incomplete
Pending -- needs correction
6omments:
eader�Siine.s
,
Satisfactory: e
- - -Pending- inc - -
3000 lb. Crzsti
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Pending -- needs correction
Comments:
Percolation Lines:
Satisfactory: Ye
" `
Pending - incomp ete
Pending =- needs correction
.,�
Comments:
Absorption Trenches:
Satisfactory: es
Pending - incomplete
Pending -- needs correction
Comments:
Other:
Septic Contractor Name
As -built sketch:
Completion Statement Received:
.Conditional permit compliance:
Time spent inspecting: Time in: Inidm)
out:
Time
Construction Final Ap roval:
Approved by
ester Supply Location:
Satisfactory: Yes
Pending - incomplete
Pending -- needs correction
Comments:
ime Spent Inspecting: Time In: I :30 Time Out:
lymos
Date Approved
Date Approved
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VIRGINIA Albemarle County Health Department
V�DH DEPARTMENT Box 7546
OF HEALTH Charlottesville, VA 22906
Protecting You and Your Environment - (434) 972-6259 Voice-.... , -
(434)972-6221 Fax
Septic Tank - Soil Absorption System Construction Permit
Health Department ID Number: 101-06-0277
Owner/ Agent Information
Owner: McRaven,..Charles '&.Linda
P.O. Box G
Free Union, VA 22940 ,
Owner Phone: (434) 973-4859 .
Property Address: 814 Davis Shop Road 7 (Tax Map: 8-16B` i
Locality: Albemarle ----
Directions: Barracks Road West to Free Union Road, turn right at Hunt County Store, go 9 miles thru Free Union
and turn right on Davis ShoD Road. ao 1 mile. turn left into property and stay left to log house.
System Type: septic tank effluent and <
Type of Property: Residential
Sewer Line
3" or 4" Sch. 40 PVC or equivalent
(cleanouts required at 50'' to 60' interva
Material: Minimum crush strength 1500#
Pipe Diameter: 4'
Minimum Slope: 6" per 106' (only for no
Number of Bedrooms: 3 maximum
Distribution Box Information.
No. of Boxes: 1
No. of Outlets: 6
Header Une Information
ASTM F405 pipe or better (1500 #
Minimum slope 2 per 100'
Capacity: 900 gallons
Slope: 2-4" per 100'
The inlet structure shall be 1-2 inches higher than the outlet
Percolation Lines: 4" diameter .
structure and shall extend 6-8 inches below and 8-10 inches
Center to Center Spacing: 9'
above the normal liquid level. The outlet structure shall extend
Installation Depth: 42" .
35-40 % below the normal liquid level and 8-10 inches above
Depth of Aggregate: 13", Size of Aggregate: 0.5-1.5" .
the normal liquid level. To comply with the maintenance
requirements of 12 VAC 5-610-817 the septic tank must be
Total Number of Laterals: 5
provided with one of the following three options: 1)-Inspection
Laterals to be 100' long, x 3' wide
port, 2) Effluent filter, 3) Reduced maintenance tank
Install 1500 Square Feet Total
100%Reserve Area Required for Future Repairs
Note:
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Construction Drawing HD ID #: 101-06-0277
38R
.. Leg Cabin
106% Reser�
Ahpb th.t Area
64N &
Rrmoaetl!
5 x100'
Slope -�
1fYe�
Drawing Not to Scale
This sewage disposal system construction permit is null and void if conditions are changed from those shown on the
application or construction permit. No part of any installation may be covered or used until inspected, corrections
made if necessary and the system is approved. The inspection will normally be made by the system designer, who
may be an AOSE, PE, or EHS. Any part of any installation which has been covered prior to approval shall be
uncovered, if necessary, upon direction of the Department or the system designer.
System Design By: Lacy Stevens; Site Evaluation By: Lacy Stevens
May 15, 2006 November 15, 2007
Lacy Stevens Issue Date Expiration Date
VDHOF
EPAR M glbemerle County Health Department
DEPARTMENT PO Box 7546
HEALTH Charlottesville, VA 22906
Protecting You and Your Environment (434) 972-6259 Voice
(434)972-6221 Fax
Private Well Construction Permit
Health' Department ID Number: 101-06-0277
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Owner/'Agenff►nformatron x,a .. _ , ._.:'s . m.. . ,� �_ .r, t ._.... .3v v... :a
Owner: McRaven, Charles & Linda
P.O. Box G
Free Union, VA 22940
Owner Phone: (434)973-4859
Property Address: ' 814 Davis Shop Road Tax Map: 8-16B
Locality: Albemarle
Directions: Barracks Road West to Free Union Road, turn right at Hunt County Store, go 9 miles thru Free Union
and turn right on Davis'Shop Road go 1 mile turn left into property and stay left to log house.
Gene`r"airtnforma"n;,
Well Class: : Class IIIC Minimum Casing Depth: 20 feet I Minimum Grout Depth: 20 feet
Comments:
This permit is issued based upon a site evaluation conducted by Lacy Stevens, EHS on May 4, 2006.
See following page for Construction Drawing.
Notice: The Virginia Department of Health may revoke or modify this permit if, at a later date, it finds the conditions that formed the
basis for issuing the permit do not substantially comply with the Private Well Regulations , 12 VAC 5-630-10 et seq., or if the well
would threaten public health or the environment.
"Page 1 of 2
Well Construction Permit -- Drawing
H D I D #: '10'1-06-0277
Ownerinformation 't fV
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McRaven, Charles & Linda Phone: (434) 973-4859
P.O. Box G
Free Union, VA 22940
Construction -Drawing ,E , t , �,�_ .. �f .� _ �,��a.u..w� _s .«�.•
Scale drawing of the well site and related features.
sn.a
nic well
Area
mee,r
a�
a%f
rtiRa
3 BR
It'dall:5 Lines
Install: Class IIIC.Well
Log Cabin
100' Long
20' Casing
3'Wtde
20' wool
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Area is 100'00 Draint eld!
—
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42" Deep
mote: 30' x 30' Well -
l.2
3•
On Ca4oa
Area Only"V,
1000 gal. Tanh
male: maple win
10'0l Drainfield
100%Resery must be Removed!
IAyk wt Area
w te,
Rmovtd
le
\S7t\1\\
MON
Drawing ma to Scale
Show the property lines, all existing and proposed structures, existing and proposed sewage systems and
water supplies, slope, and any topographic features which may impact the design of the well.
A May 15, 2006 November 15, 2007 .
Issued by: Lacy Stevens Issue Date ..Expiration Date
Page 2 of 2
J11L 11J11 •1V1111011LL.
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Date: ab aZp � Cp
HD ID ": �0/ - bco - (—) c;- %
Owner:
�1
LindCkj
Directions
Type of Well to be Installed: [iTA
IIIB IIC IV Additional Grout: YES NO Amount:
Evaluation Methdd: Hand Auger
Piu Other -
Position in Landscape Satisfactory:
YES NO
Position Type: Sideslop Other:
Slope: I
Imo/
Depth'to Rock/Impervious Strata:
Depth of Seasonal Water. �
Free Water Present: YES NO"
Other Limiting Feature Present? YES
.N Description:
Soil Group: I II III
IV Permeability: Minutes Per Inch.
Permeability Estimated At:
inches ' Permeability Test Performed:. YES,
.,
a .r
Treatinent Level; Prima
Secondary Advanced Secondary • " i
Length of.Site (On Contour): On
width ofSite .(Up &•Down Hill):
Septic Tank Capacity (Gallons):, 750
90 1200 1500 Number of Septic Tanks:
Distribution: Grav' Pump
Enhanced Flow Number of Boxes;, Other__ .
Conveyance Line Diameter: 4"
Other: Number of Ports Per Box:Other .
._'.:.:.. -.. _.: Y..:...... .. ... .c.. _....: .v,.. f.Y
Pu Specifications: Putn
a ber Size, gallons V, Day Storage: gallons
Drawdown (Eac in ycle):
ons inches -
Maximum Pump Cycl e•
ins. Secs. .. Minimum Pump Capacity: GPI
Pump ovide a inimum f_
gallons per minutes at System Head.
AbsorptionArea: Number of laterals: 5 Lengch:, IO0 Feet Width: 3' 0[her.
Center to Center:
10' 1 P - Other:
Aeeregare Depth
li" Other: Installation Depth:
Time In: IQ (i 7
-
Time Out•. I a 0 0
¢ironmentnl at _Specialist senior, Signature
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Date of Evaluation Profile Description Health Department l�' �xo
SOIL EVALUATION REPORT Identification No.
a�' ;
Page of
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 I evaluations .a. a conducted by a private, soil scientist. location of pro-,
file holes and sketch of the area investigated including all structural failures i.e.. sewage disposal systems. wells. etc., within 100 feetof site
(See Section 4) and reserve site shelf he shown on the reverse side of'nis page or prepared on a separate page and attached to this form.
❑ Sea application sketch ❑ Seeconstruction permit- ❑ See sketch on reverse side or ,
- page attached to this form.
Hole Horizon '
'Depth (Inches) 7
1". Description of, color, texture, etc. .
- Texture Group :
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Thomas Jefferson Health District
Albemarle/Charlottesville Health Department
Environmental Health Services
Application for a Sewage Disposal and Water Supply Permit
TO BE COMPLETED BY APPLICANT
Building/Facility:
idNew
[ ] Existing
Termite Treatment
[ ] Yes
WNo
Basement
(] Yes
No .
ONo
Plumbing in Basement
[ ] Yes
5/75l/V h
Water Supply: Public [ ] New [ ] Existing
I Private `New [ ] Existing
Describe C�CLG %� Q L" (%(
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 PROPERTY DESCRIBED FOR THE
�OC�G THIS
� PPL�ON.
Signature of Owner/Agent Date
1 FOR OFFICE USE ONLY 1
Date Application Received: - I6Ag f �W`y
Health Department ID: I l_J� D /�--� 1
Receipt Number: 2 -- ((�
Date of Site Visit Ll lap Time 10 D -'(30
Appoint)ntents may be cancelled due to rainorinclement weather
EHS Scheduled law � ( ) k �' �t- 4 s,
Please review vour "Checklist' before your scheduled appointment -If the specialist arrives at the site and those
items have not been addressed, he/she may leave the lot and you will be rescheduled at the end of the waiting list.
k
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,Data -
` BUILD
County ofA
Applicant to complete 401 Mclnt T, B
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numbered spaces only " cam" FE
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';W0 i3 f7a0-Oy-Oo .olr��,
Land Use' -Yes—�,�PIO.
IG PER+MIT Permit k
arleJ' I n speck ons€De pt.
irlottesville, Va. '22902-4596 Project #
:`(804)• 296-5832
)4) 972-44060
4 f 7�
NAME t: s
a
R
WHEN PROPERLY VALIDATED'-LIN THIS SPACE) THIS IS YOUR PERMIT
APPLICATION TAKEN BY: IMP PERMIT VALIDATION , .0.' CASH '
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Thomas Jefferson Health District
Environmental Health Services
Important Notice
Please Read Before Filing Your Application and Paying Your Fee.
This is to inform you that the fees, for Environmental Health permits mandated by the state,
cannot be refunded once the application has been filed and the fee paid; except for the following
reasons:
• If the applicant withdraws their application before the Environmental Health Specialist makes .
a site visit to evaluate the property and if the applicant requests a refund in writing.
• The health department is unable to, issue a permit and only then if:
A. You are seeking to construct your principal place of residence on this lot, and only then
if:..
B. You provide written notification to the health department that you are foregoing your
right to appeal the denial of your request for a permit and include your social security .
number. In order for you to then appeal at a later date, the above refunded fee would need
to be re -instated before a hearing date would be scheduled. Please note that because this
is a state agency, if you have a debt with the state, your refund would go towards your
account.'
• The Albemarle County Onsite Well and Septic Application fee may be refunded for the
above reasons.
NON-AOSE APPLICATIONS will become void if it inactive for 90 days. After that time, a
new application and payment of all applicable fees will be required. INCOMPLETE AOSE
APLLICATION PACKETS will be denied. Applicants will have 90 days to resubmit complete
application packet. After 90 days payment of all' applicable fees will be required: Once a pernut
has been issued, it is valid for 18 months:
It is your responsibility to have the comers of property lines of a lot clearly marked and to have -
the four comers of the proposed house site flagged. The Environmental Health Specialist will not
be able to complete work without these markings. The soil evaluation may not be performed if
the site has not been adequately marked. Also, if the lot is too overgrown,then the Environmental
Health Specialist may require bush hogging, etc. before site work can be done.
It is also your responsibility to make it clear to the Environmental Health Specialist which one or
two areas on yoirr lot you want tested, although he will advise you which area appears more.
suitable for a septic system. No more than two areas will be tested and the permit will be issued ,
showing the location of the system in only one suitable site.
Sites that have been previously approved during division of property, etc. or sites that have
previously issued permits cannot be changed without additional expense on your part. If this
occurs, you will need to hire a private soil consultant to test another site and submit a report
showing conflict with neighboring lots. New application and fee will be required.
have read and understand the above application notice.
- ----- i f— - - - ---------Date: -- �/�------------- -
11
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Owner / V (C �iQ je 0, �/ )0 12,E `� -Q IXk't)
Agent.,
Tax, Hap #:
Subdivision
Combination Per pRepair Permit ❑Septle Permit
❑Certification Letter' ❑Well Permit ❑Well Abandonment
oSepti& Well .
oSeptie
Da
Ini
APPlication'Received ;.
Assigned To: joc U S
Lq
(y
AOSE'Submittal ❑ Yes bNo
Site VisitScheduled
Time: IV•� �V ;'
COIITMENTSr Ji r�C� �4 C i 1PCt .
ef�
Site Visit Rescheduled 1 a a P l j )--but Q II iC ll.
Time:
Site Visit Made
Date Given to OSS S
Data Entry
Construction Permit ❑Issued �Denfed
Certification Letter '❑Issued ❑Denied
Survey Received OYes ❑No
Construction Permit Mailed 4i
Construction Permit Picked — Up '
Septic Maintenance
y,
Water Supply and/or Sewage Disposal System Construction Permit Page 1 of3
k' Commonwealth of Virginia Health Department
Department of Health - Identification mber: 1q01-95-0216
ALBE24ARLE CO. HEALTH DEPARTMENT, Tax Map Number: 8 16B �] /
r,
General Information - BP#: 95-538 SF
Water Supply System: NEW Sewage Di osa System: NEW
Based on the application fora sewage disposal system construction permit filed in ordan ith Section 2.13 E, of the
Sewage Handling and Disposal Regulations and/or Section 2.13 of the Private lations a.construction permit is eby issued to:
Owner: CHARLES MCRAVEN Telepho 4-973-4859
Address: BOX "G", FREE UNION, VA 22940
For a Type I Sewage Disposal System or Well t onstruct o at
TO THE NORTH OF RT. 671 1.3 MILES EAST OF R '
�• Sec/Bk Lot Actual orestim d r use 50 d - bedrooms
DESIGN OTE: SEWAG OSAL S&FSTEM INSPECTION RESULTS
Water supply, TO BE INSTALLEDgat
er su 1 1 atio
Satisfactory
yes_
-no_
To be installed: CLASS: I IIC
CASED: 20"feet GROUTED: 20 fe
G. Re ed: es
_ no not applicable_
Building Sewer: I.D. PVC S�11e 40,
B e
Satisfactory
yes_
no
or equivalent. SPe 1.25" per 0 t( 'n.)
'
Other
Septic Tank: Capacity: 900 Galsmin.
trea nt unit:
Satisfactory
yes_
no
Other
Inlet -outlet structure: PVC chisdule 40,
In -outlet structure:
Satisfactory
yes_
no_
4" tees or equivalent.
Other
Pump and pump station:
Pump & pump station:
Satisfactory
yes_
no_
NO
Gravity mains: 3" or larger I.D.,
method:
Satisfactory
yes_no_fall
min/Conveyance
per 100 ft., 1500 lb. crush s
or equivalent. Other
Distribution Box: Precast concre
Distribution box:
Satisfactory
yes_
no
with 5 ports.
Other
Header lines: Material/4"D 1500 lb.
Header lines:
Satisfactory
yes_
no_
crush strength plasticvalent from
distribution box to 2 absorption
trench. Slope 2" min.
Percolation lines: Gr i 4" plastic
Percolation lines:
Satisfactory
yes_
no
1000 lb. per foot b ri g load or equiv..
slope 2" - 4" (min ma .) per A00ft
Other
Absorption tr736Depth
Absorption trenches:
Satisfactory
yes_
no_
Sq ft. requir00 depth from
ground surlattom of trench 42":
aggregate z5":
Trench bo om2-4"/100 ft
center t cencing 9 FT:
Date
Inspected and approved
by:
Trench idth of aggregate 13":
Trenc lengtht:
Environmental
Health Specialists
Numb of trenches 4
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Health Department �y� _ �r I 6
Identification Number l�
Schematic drawing of sewage disposal and/or water supply system and topographic features.
Show the lot lines of the building site, sketch of property showing any topographic features which may impact on the design of the
well or sewage disposal system, including existing and/or proposed structures and sewage disposal systems and wells within 200
feet. The schematic drawing of the well site or area and/or sewage disposal system shall show sewer lines, pretreatment unit,
pump station, conveyance system, and subsurface soil absorption system, reserve area, etc. When a nonpublic drinking water
Kc
p"yis to be permitted, show all sources of pollution within 200 feet.
rhe information required above has been drawn on the attached copy of the sketch submitted with the application.
h additional sheets as necessary to illustrate the design. '
n
50' ALL CONTRACTORS SHALL BE LICENSED BY
well THE COMMERSE DEPT,
area 50 ALL DRY HOLES SHALL BE ABANDONED IN
ACCORDANCE WITH THE PRIVATE WELL REGS,
50' 100'
10, res Ve
35' sits n 1919191 ar
100' 30'
50' ,
4-100'x3' lines
9' centers
exist, Bldg, 42" deep
This sewage di posal system and/or water supply is to be constructed as specified by
the permi or attached plans and specifications _ .
no scale
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 Departmen
Date: Issued by: _ This Construction
n Tian Permit Valid ntil
Date: Reviewed by: /
Supervisory Sanitarian
If FHA or VA financing
Reviewed by Date
C.H.S. 202B
Supervisory Sanitarian
Regional Sanitarian
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This sewage disposal system
application (b) conditions -are'.
No part of any installation s
department or unless expres
approval shall be uncover�d,
Date:
Date:
Health Department
Identification Number—%—
—7rl
Schematic drawing of sewage disposal and/or water -supply system and topographic features.
Show the lot lines of the building site, sketch 'of pr6perty:showing any topographicnt uni ,
3f /th features whqt� may impact'on,the design of th 1 0
well or sewage disposal system,.including existing and/or proposed structures and sewage disposal systems anc1wells within 0
The schematic drawing of the well site or area and/or sewage disposal system shall show sewer lines, pretreatme
nt e
pump station, conveyance system, and subsurface soil absorption system, reserve area, etc. When a nonpublic drinking ter
s pp 'y is to be permitted, show all sources of pollution within 200 feet.
h information required above has been drawn on the attached -copyof the sketch submitted with eapplication.
The
tth additional sheets as necessary to illustrate the design.
q-
501 ALL CONTRACTORS 'SHALL -
THE COMMERSE'-DEPT.
W�l 50' 1
XICENSED BY,
area ALL DRY HOLES SHALL Le ABANDONED. IN
I ACCORDANC—E,�41Tk THE Le
ATE WELL REGS,
ZVI
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ro es e*
cab rt
-sift
.
35 .t. t1t
50
exist, bldg. _7Y
This sewage di posal ystem and/or water supply is to be constructed as specified by
the permi r att ched plans and specifications
7 no scale
a d/or well construction permit is null and void if (a) conditions are changed from those shown on the
c anged from those shown on tfidconsiructior'permit. I . . .
lines
deep
all be covered , or used until inspected, correctionsde if ec ssary: and approved, by the local health
sly authorized by the local health dept. Any part stallation which iis been covered prior to
if necessary, upon the direction of the Departme
Issued by:
Reviewed by:
---------------------------------------------------------------
if FHA or VA I inancing
This Construction
.%43am;arian
Permit Valid ntil
Supervisory Sanitarian
---------------------------------- --------- ------
z
Reviewed by Date
C. H.S. 202E
I e
Supervisory Sanitarian
FILE COPY
Regional Sanitarian
ED ID #!: Tax Map ## - A L3 page 3
See Page #2 for Design Drawwg. This Drawing is Not to Scale.
SEWAGE DISPOSAL AND WATER SUPPLY CONSTRUCTION PERMITS:
' Permit is void if the house location interferes with the. proposed well or drainfteld/reserve locations.
Follow all OSHA requirements.
` Minimum separation between drainfield/rererve areas) and well sites is 100' for Class HIC wells and 50' for Class 711E
wain This distance increases by 25'for every 5% *ofslope for welLr down slope of any source of contamination (house siie; N
drainfield/reserve areas, etc)-
.
` It is the o
utilities wner's r esponsibility to ensure that the weU and septic syst
and easements. em .is on the property and, does not interfere with' "•
* Health I7eyartntenu's Operation Permit and Well Inspection Report required prior to occupancy.'
* All septic and well contractors must haw a current he,
nse with the Va. Dept.. of Comrnertae_ .
It isillegal to put either well or septic syston into use without fittdl health department approval.
* Septic & Well Contractors should be '. .. _ provided with a mpy of ppmit before any construction begans,
SEWAGE DISPOSAL CONSTRUCTION PERMITS:
* Basement 07oor is below surface of ground)? YES<ga�aaow YES NO
* Fiziures in basement? YES NO, ,If yes, is lift Pump required?. YES NO`
Pump is required when the ground surface over the drain
or the sewer line leaving the house. field trenches is at a higher elevation than any pltunbing fixture.
* Do nor disturb, thedrainfidd or reserve area(s).'
ervice shall be closer than 10•' to any pan of .this system.
No buried utility s
* Do not install drainffeld system during periods of 'wet weather or wet soil. - -
* It is recommended that all trees be removed from the drainfteld
area MUST removed.
area and all hydrophilic trees within 10' of the drainfield
* Placed untreated building .
Paper or approved material over the trends gravel.
* The maximum soil cover over se tic/ t -
P ParaP tanks and distribution bases is 18" to 24 ".
* - AU tanks shall be watertight. -
* Final grade of drainfteld shall be crowned to divert surface. water & Prevent
P ponding.
" Roof drains, basement sum'
etc being P discharges ('man-sewa8e), f7oordrains, footing drains, dischargefrom wafer treatment systems,
$ connected to this system s PROHIBITED! Divert these twayfrom drainfield.
Keep structures and driveways off dra
-
infield/reserve area(s).
` It shall be the responsibilitya t
sewage d' f he o"'� or any subsequent owner ro maintain, repair or replace (requires a pmnitJ and
$ disposal ssstem that ceases to operated in a sanitary manner.
* Is septic tank locution in a PLaCe Of s -
instmaions on placing tanks ins r high water table? YES O
Please refer to tank manufacturer's
WATER SUPPLY CONSTRUCTION PERMITS
* Well and all water lines shall be disinfected prior to ware, sampling.
Dry holes must be permanently abandoned in accordance with the Private, Well Regulations. -
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CHARLES MCRAVEN
BOX."Gn ,
FREE UNION, VA 22940
RE: PERMIT,ID # 101-95-0216
DEAR CHARLES MCRAVEN:
Any water well installed in Virginia must meet „ specfic•
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., Contact your local health department
for 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,,
William A. Craun
Environmental'Health Specialist Senior
ID #: 101-95-0216
OWNER'S NAME: CHARLES MCRAVEN
ASSIGNED'TO: William Craun
SYSTEM TYPE
I G
WELL TYPE
TRENCH DEPTH
NO. OF TRENCHES
UU
LENGHT OF TRENCHES.
C` tC
DITCH CENTERS
SLOPED?�
PERK RATE
MAIL TO
SOIL INFORMATION
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DATE: -
DIRECTIONS:
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DEPTH TO ROCK
DEPTH TO WATER TABLE•
DEPTH TO FREE WATER
TEXTURE GROUP
PUMP LETTER 0. r
Lift
Gals
SEE BACK FOR SKETCH
_TEXTURE GR
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Soil Evaluation Form PAGE ' 1 OF 2
Commonwealth of Virginia Health Department
Department of Health Identification N mber: 101-95-0216
Tax Map Number W16B
General Information
Date: May 31, 1995 ALBEMARLE CO. HEALTH DEPARTMENT'
Applicant: -SEE ATTACHED APPLICATION Telephone No.:
Address: '
Owner: CHARLES MCRAVEN
Address: BOX "G", FREE UNION, VA 22940
Location: TO THE NORTH OF RT. 671 1.3 MILES EAST OF RT. 601
Block/Section: _Lot:
Soil Information Summary ..
1. Position.in landscape satisfactory
2. Slope: 5 $.
to Describe
3. Depth to rock/impervious strata NOT ENCOUNTERED:
4..Depth to seasonal water table (gray mottling or gray color) NOT ENCOUNTERED:
5. Free water present- NOT ENCOUNTERED:
6. Soil percolation rate estimated S: Texture group: III
Estimated rate:- 53 min/inch
7. Percolation test performed Number of percolation test holes:
No: Depth of percolation test holes:
ge percolation rate:
Name and title of evaluator: William �Craun,_ Environmental Healt
Signature:
Department Use
Site Approved: Drainfield to be placed at 42" depth at site designated on permit
C.H.S. 201A Revised 4/87
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Profile Description
SOIL EVALUATION REPORT
Date of Evaluation: May 31, 1995 Health Department
Identification No. 101-95-0216
Page _ of
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.
See application sketch _ See construction permit _ See sketch on reverse or page attached to this form
Hole # Horizon Depth(inches) Description of color, texture; etc. Texture Group
1 A 0-8 .BROWN LOAM II
B 8-30 RED MED. CLAY LOAM III
C 30-60 RED LT. CLAY LOAM III
2 'A 0-10 BROWN LOAM "II ,
B 10-28 RED MED. CLAY LOAM, III
C 28-60 RED BROWN MICA CLAY LOAM III
3 A
B
C
0-10 BROWN LOAM
10-26 RED MED./LT. CLAY LOAM
26-60 RED LT. CLAY. LOAM
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Record Of Inspection -Nonpublic Drinking Water Supply,''System,- `
Use of form required onlywhen Health Department .
Commonwealth of Virginia., a De artment of Health . water supply constructed i
n con- I.DNumber,
p junction' with 'an on -site sewage _ -
disposal system, or when FHA, VA
F.H.A. orb:A. Case Number financing is involved. Map Reference ,. .
•` If Applicable
- .Date Local.Health Department .
Owner Address Phone
_..Exact Location. of Premises
';S'ubdivision �Section/Block1' ^' Lot
Classsof'nonpublic drinking water well: 1) Class,„III : A. -(drilled well) ❑.
2) Class III • B. (bored well) ❑
. _3) Class IIIC..(jetted well) ❑
4) Class •III D'.. (dug well) ❑ ..
Date' of installation 5) Other E. ❑
CONSTRUCTION INFORMATION
i If information -in any item below is secured from other sources (i.e.) well log; etc., so note.
1'.- Water.well completion repert filed as required by 18.02.07 :Yes'❑ NoEJ
-;,2. Well Location: Distances from sources of pollution (see Table 12.1, Minimum Separation, Distances) and Section'
10.04.01 and j18.02.02. '
Building Sewer Pretreatment Unit Conveyance System Subsurface'
Soil Absorption System (nearestpoint). Property, Line Other
Site graded where necessary to divert water- away:from well? Yes ❑ ❑ No n.a. ❑
3.. Construction, General: (see Section 18.02.05, and 18.02.02)
Total depth of well feet. Type of casing .Depth of casing feet. Diameter
of casing - inches. Casing extends inches above ground . Exterior space around casing sealed'
with neat cement grout to a depth of feet. Screens constructed of
free of rough edges and irregularities, with positive watertight seal between screen and casing? ❑ yes no ❑
n.a. ❑ Well head and opening to the interior protected? yes ❑ no ❑ Type of well seal
Pitlesss-adapter used? yes ❑ no ❑ n.a. ❑ Properly installed? yes ❑ no ❑ n.a. ❑ Proper venting?
yes ❑ no ❑ n.a. ❑
4. Quantity: Yield and drawdown determined by continuous pumping of hours. Drawdown feet.
Yield GPM. Type of storage
5. Quality: Sample tap provided at entry into system? yes ❑ no`❑ Sample(s) collected? yes ❑ no ❑
Results of samples. Satisfactory ❑ Unsatisfactory ❑ (attach copy of results to this form)
Based on the inspection of this water.supply system and the information contained on the water well completion report
attached, this water supply is approved. ❑
Remarks:
Date
Date
Date
' 'C.H.S. 204' Rev. 4/83
Signed
Sanitarian
Signed
Supervisory Sanitarian
Signed
Regional Sanitarian (If V.A. or F.H.A.)
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Record Of Inspection,— Nonpublic Drinking Water Supply System
Commonwealth of Virginia use of form required only when Health Department
Department of Health water supply constructed in con-
junction with an on -site sewage I.D. Number
disposal system, or when FHA, VA
financing is involved. Map Reference
F.H.A. or V.A. Case Number
If Applicable
Date
Owner
Exact Location of Premises
Local Health Department
Address
Phone
Subdivision . Section/Block
Lot
Class of nonpublic drinking water well. 1) Class III
A.
(drilled well)
❑
2) Class III
B.
(bored well)
❑
3) Class III
C.
(jetted well)
❑
4) Class III
D.
(dug well)
❑
Date of installation 5) Other
E.
❑
CONSTRUCTION INFORMATION
If information in any item below is secured from other sources (i.e.) well log, etc., so note.
1. Water well completion report filed as required by 18.02.07. Yes ❑ .No ❑
2. Well Location: Distances from sources of pollution_ (see Table 12.1, Minimum Separation Distances) and Section
10.04.01 and 18.02.02.
Building Sewer Pretreatment Unit Conveyance System Subsurface
Soil Absorption System (nearest point). Property Line Other
Site graded where necessary to divert water, away; from well? Yes ❑ ❑ No n.a. ❑
3. Construction, General: (see Section 18.02.06, and 18.02.02)
Total depth of well feet. Type of casing Depth of casing feet. Diameter
of casing inches. Casing extends inches above ground . Exterior space around casing sealed
with neat cement grout to a depth of feet. Screens constructed of
free of rough edges and irregularities, with positive watertight -seal between screen and casing? ❑ yes no ❑
n.a. ❑ Well head and opening to the interior protected? yes ❑ no ❑ Type of well seal
Pitless adapter used? yes ❑ no ❑ n.a. ❑ Properly installed? yes ❑ no ❑ n.a. ❑ Proper venting?
yes ❑ no ❑ n.a. ❑
4. Quantity: Yield and drawdown determined by continuous pumping of hours. Drawdown feet.
Yield GPM. Type of storage
5. Quality: Sample tap provided at entry into system? yes ❑ no ❑ Sample(s) collected? yes ❑ no ❑
Results of samples. Satisfactory ❑ Unsatisfactory ❑ (attach copy of results to this form)
Based on the inspection of this water supply system and the information contained on the water well completion report
attached, this water supply is approved. ❑
Remarks:
Date Signed
Date Signed
Date Signed
C.H.S. 204 Rev. 4/83
Sanitarian
Supervisory Sanitarian
Regional Sanitarian (If V.A. or F.H.A.)
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Record Of Inspection=Nonpublic Drinking -Water Supply System
Commonwealth of Virginia Use of form required only when Health Department
Department of Health water supply constructed in con- I.D. Number
junction with an on -site sewage
disposal system, or when FHA, VA
financing is involved. Map Reference
F.H.A. or V.A. Case Number
If Applicable
Date
Owner
Exact Location of. Premises
Local Health Department
Address
C�
Phone
Subdivision Section/Block Lot '
Class of nonpublic drinking water well. 1) Class III A. (drilled well) ❑
2) Class III B. (bored well) ❑
3) Class III C. (jetted well) ❑
4) Class III D. (dug well) ❑
Date of installation 5) Other E. ❑
CONSTRUCTION INFORMATION
If information in any item below is secured from other sources (i.e.) well log, etc., so note.
1. Water well completion repot filed as required by 18.02.07. Yes ❑ No ❑
2. Well Location: Distances from sources of pollution (see Table 12.1, Minimum Separation Distances) and Section
10.04.01 and 18.02.02.
Building Sewer Pretreatment Unit Conveyance System Subsurface
Soil Absorption System (nearest point). Property Line Other
Site graded where necessary to divert water away from well? Yes ❑ ❑ No n.a. ❑
3. Construction, General: (see Section 18.02.05, and 18.02.02)
Total depth of well feet. Type of casing . Depth of casing feet. Diameter
of casing inches. Casing extends inches above ground . Exterior space around casing sealed
with neat cement grout to a depth of feet. Screens constructed of
free of rough edges and irregularities, with positive watertight seal between screen and casing? ❑ yes no ❑
n.a. ❑ .Well head and opening to the interior protected? yes ❑ no ❑ Type of well seal
Pitless adapter used? yes ❑ no ❑ n.a. ❑ Properly installed? yes ❑ no ❑ n.a. ❑ Proper venting?
yes ❑ no ❑ n.a. ❑
4. Quantity: Yield and drawdown determined by continuous pumping of hours. Drawdown feet.
Yield GPM. Type of storage
5. Quality: Sample tap provided at entry into system? yes ❑ no ❑ Sample(s) collected? yes ❑ no ❑
Results of samples. Satisfactory ❑ Unsatisfactory ❑ (attach copy of results to this form)
Based on the inspection of this water supply system and the information contained on the water well completion report
attached, this water supply is approved. ❑
Remarks:
Date Signed
Date Signed
Date
C.H.S. 204 ReV. 4/83
Signed
_ t
Sanitarian
Supervisory Sanitarian
Regional Sanitarian (if V.A. or F.H.A.)
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Application for a Sewage Dispdsal"System Construction Permit
Commonwealth of Virginia For Department Use Only Health Department �/ s G
Department of Health +epn cation Numbepa_RS3 g S� �Q����ok
ference Health Department EL" 9ate.Received
To Be Completed By The Applicant
Type sewage system: New ❑ Repair ❑ Expanded ❑ Conditional
FHA/VA yes no ❑
/ ` V f- .ram
Owner ��,{/�l�f ,lr�>✓ Address�d+� tom- ry Phone ) '
Agent Address Phone
Directions to Property 4 ml'6
AN&,
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Subdivision
T
Section Block Lot',
Other Property Identification
Dimensions/size of Lot/Property ��SOO
Q
— �O_ pQ — 6 /a p04
Other Application Information
I. Building/facllUy
Z New
❑ Existing
Intermittent Use
❑ Yes
❑ No If yes, describe:
It. Residential Use
(v]'Yes
❑ No
Termite Treatment
❑ YPS
Family
❑ No
Multifamily Number
ER�Single
❑ of Units — Number of Bedrooms
Basement
❑ Yes
2440
Fixtures In Basement
❑ Yes }
No
;-No
Ill. Commercial Use
❑'. Ye�
Describe:
Commercial/Wastewater ❑ Yes ❑ No Number of Patrons _ Number of Employees —
If yes, give volumes and describe---
IV. Water Supply: ❑ blic New Describe: WO-d
Private ❑ Exis '
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 drainfiel6. Distances may be paced
or estimated.
The property lines and building location are clearly maiked 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 applic ,
yitrd4 a f l��1gnt2� !
Signature of owner/agent D to
C.H.S. M RMW 4/83
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A0plication foiYa Sewage Dispc3saFSystem 'Construction Permit
Commonwealth of Virginia For Department Use Only Health Department / � I S U 1
Department of Health Identification Number. I
qS J7 g S / Map Reference
Health Department Date Received
To Be Completed By The Applicant
Type sewage system: gv New ❑ Repair ❑ Expanded c ❑ Conditional
FHA/VA yes ❑ no- ❑
Owner � i r�(� 16 ( Address 1B (r w Phone
I
Agent
Directions to Property
tr
Subdivision
Address Phone
Dorf`-/ B/ %144, j 411 AW �/il , {,f,dw e�,71 .l u
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' - Section f Block
Other Property Identification` `
Dimensions/size of Lot/P`roperty D080, o — 00- 00 — 6 J Z, BOO -
Other Application Information
i
1. Building/facility ' Q New' ❑ Existing
Intermittent Use ❑ Yes ❑ No If yes, describe:
B. Residential Use p Y6es ❑ No J
Termite Treatment
Basement
Fixtures In Basement
III. Commercial Use
❑ Yes
ff�'Single Family
❑ Yes
❑ Yes
❑ Yes
Commercial/Wastewater ❑ Yes
If yes, give volumes and describe
IV. Water Supply:
Private
V. Proposed Installation:
If'other, describe
Lot
1
❑:No 1
❑ Multifamily Number of Units — Number of Bedrooms
ElNNNo
`k . No Describe: '
❑ No ,Number of Patrons _ ZNumber of Employees —
❑v New""" Describe: Woe
❑ Existing
�] S is tank and drainfield ❑ Other
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 mayba paced
or estimated.
The property lines and building location are clearly maiked 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 applica tin.
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Signature of owner/agent � Date
C.H.S. 200 RSMMd //83
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iplication fo'r'a S
N
wage Disposal";
('Construction Permit
Commonwealth of Virginia For Department Use Only Health Department
Department of Health Q S3 Identification Number
I S� Map Reference
Health Department Date Received
To Be Completed By The Applicant
Type sewage system: v New ❑ Repair ❑ Expanded ❑ Conditional
FHA/VA y/esr❑ no ❑
Owner C 1f /%A /✓ Address 1B .! y Phone
Agent
Directions to Property
Subdivision
Other Property Identification
Address' Phone
r
Section _ Block Lot
Dimensions/size of Lot/Property c908OD — c9U- Do — b I Zo p00
Other Application Information
1. Building/facility E New ❑ Existing
Intermittent Use ❑ Yes ❑ No If yes, describe:
t
If. Residential Use
Termite Treatment
Basement
Fixtures in Basement
Ill. Commercial Use
p Yes
❑ Yes
94ingle Family
❑ Yes
❑ Yes
❑ Yes
Commercial/Wastewater ❑ Yes
-r� If yes, give volumes and describe.
IV. Water Supply:
V. Proposed Installation:
If other, describe —
❑ No
❑ No
❑ Multifamily Number of Units Number of Bedrooms
v
No Describe:
❑ No -'Number of Patrons _ Number of Employees —
/
r�NeW--- Describe:
Private ❑ Existing
v Septic tank
drainfield ❑
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 maybe paced
or estimated.
The property lines and building location are clearly matked and the property is sufficiently visible to see the to-
pography. 1 give permission to the Department to enter onto the property described for the purpose of processing
this application
`W
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Signature of owner/agent ' J Date
C.H.8. 200 aMwd 4/83
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THOMAS JEFFERSON HEALTH DISTRICT
M"RTAWr NOTICE
Please Read Before Fling Your Application
And Paying Your Fee
This is to inform you that the fees for Environmental Health permits mandated by the State, cannot
be refunded once the application has been filed and the fee paid except for the following reasons:
1. If the applicant withdraws their application before the Environmental Health Specialist makes
a site visit to evaluate the property and if a refund is requested by the applicant.
2. The health department is unable to issue a permit and only then if:
a. you.are seeking to construct your principal place of residence on this lot, and only then
if...
I
byou provide written notification to the health -department that you are foregoing your right
to,appeal the denial of your request for a permit and include your social security number.
In order for you to then appeal at a later date, the above refunded fee would need to be
re -instated before a hearing date would be scheduled.
3. The Albemarle County Onsite Well & Septic Application fee may be refunded' for the above
reasons.
This application will become void if it is inactive for six months. After that time, a new application
and payment of all applicable fees will be required.
If you do not intend to build now but only need the soil tested before a sale is made, we recommend
that you hire a soil consultant to do the test and apply for a health department permit when you know
where you want to build. It is your responsibility to have the corners of property lines of a lot
clearly marked and to have the four corners of the proposed house site flogged. The Environmental
Health Specialist will not be able to complete work without these markings. He may refuse to
perform the soil study if this has not been done. Also, if the lot is too overgrown, then the
Environmental Health Specialist may require bushogging, etc., before site work can be done.
It is also your responsibility to make it clear to the Environmental Health Specialist which one or
two areas on your lot you want tested, although he will advise you which areas appear more suitable
for a septic system. No more than two areas will be tested and the permit will be issued showing the
location of the system in only one suitable site. The site cannot be changed later without additional
I HAVE READ AND UNDERSTAND THE ABOVE APPLICATION NOTICE.
aZWgnature��---------------- -------
Sif Applicant Date
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TAX MAP: B
[_ I Septic
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[.1 Well.
SUBDIVISI/OyNp
N OWNER:
LOT.
[t�Combination
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[ ]Repairs
j
DATE
INITIALS .
1
Application Received
1
Fee Determined; Reviewed) -
-
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Assigned to:-Ll L
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Site Vsit,Scheduled: Time: /,�.3� lowx
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site visit Rescheduled.
I`
Site Visit Made:
To OSA for Data Entry:
Returned, to EH Staff`
s . /Deny Drafted:
---t---
Given to Reviewer:
�— _
' Issue/Deny Reviewed:
Issue/Deny Countersigned:
Given to OSA/EH Staf
Issue/Deny Hailed:
�—
Issue/Deny Picked Up:
CIO �10/2007 10:4 434973356
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P,11::R:Y%.IEN RESTOR4TNS PRGE 02 i
biological, Chemical. and Physical Analysis of Water, Ai.r; and Solids;
i bioloaical and Chemical Treatability Studies; Flow Measuramenis
P.0 Bey 4006 : Charlottesville, Va. 2903-0841
• Phone. r4302K-1716
(.) i/I .<:1 :)b
'FAC:"fF'F:.IL'll_17igI'CAL. AIVAt.YSTb NIS:1='Cll�'i
TOTAL. COL,117O','M IN DRINYc.IN6 WATER
JOe IVI-IMF,ER:
`,'l1MF=I.. E' NUM F�ECR• 7E;')7u -
DATF,-. REPCJF,TED: �i5/� � I. / OE
IDF_NTIFICATION;
MCF'LWEN WELL... 'S-l=it_r; 05
SAMPLE MEETS STATE STANDARD F'DR C:OLIF()F.:M BBC"FER'10
IN DRINKING WATER, TOTAL. COLIFORMS WERE NOT DEFECTED.
E.C:OL,I BACTERIA WER IVl.7T DETECTED.
RUN BY" TN1F F:Y:.11_'1 TiaP� FNOC:-L`I')URE:.
H (7lJta-AIR L..AROG'A'J :S, II'd C:�
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COSLMON'WEALTH OF VIRGLNIA
(. NVFORNA,WATER WELL CONEPLE170N REPORT
OWNER n M-EL ZA. e TAX MAP M I l 6
ADDRESS; VDH PERMITQa7'7
kAqi�Ov% VP -I-L4WO VWCB PERMIT
PHONE IY34 - q?3- COUrTY,Qtb omor(G
WELL DATA
GENERAL INFORMATION GROUT �t
DRILLING METHOD A O f V FROM O TO 20 T.
DEPTH TO BEDROCK Go rz, SORE HOLE SIZE _ O c
STATIC WATER LEVEL - TYPE h. i--G
WELL DISINFECTED (Y OR M METHOD 4X2ij ne _
RECEI VEp
MAY 3 1, 2906
ENVIRONMENTAL HEALTH
TOTAL DEPTH OF WELL % SS iT CASLgG
LENGTH OF TEST a . FROM O TO li 0 s' ,
NATURAL FLOW SIZES MATERI�VC,
AMOUNT USED WTIGHTlSCHEDULE
DATE Co-vP�ErED
YIELD (GPM)
STABILIZED WATER LEVEL
DISINIFECT ANT USED
PRIVATE WELL: DOMESTIC Ii�GRICULTURAL_ INDUSTRIAL_ MONITORLING_
PUBLIC WELL: COMMUNITY NON COMMUNITY
DRILLERS. LOG
DEPTH DESCRIPTION OF FORMATION OR SEDAdENT REMARKS
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I certify that the information contained here is uw and that this well was installed and constructed in ac=dance with the pttmit and
further that the well complies with all applicable steae and local regulations, ordinances and laws.
NAME MATHENY WELL DRILLING & PUMP SERVICE. INC.
ADDRESS 2797 KACEY LANE
AFTON. V.A. 22920
PHONE N 49849 118�t�t to .yam
DRILLERS S GNA
DATE Sf O 'REPRESENTING
VIRGINIA CONTRACTORS LICENSE NUMBER 017281