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HomeMy WebLinkAboutSUB202300030 Approval - Agencies 2023-03-02Sewage. Disposal System Operation :Permit: Commonwealth of Virginia. Department of Health Health Department , Tax Map. No. 26-20-96 t to Operate a Identification No: IW-92-f)3t)f) ALBEMARLE CO. Health Department t Sewage Disposal System Having a fEST OF RT. 674 .2 MILE NORTH 0 is Hereby Granted Permission of 450 gpd, at SUBDIVISION . SECTION/BLOCK LOT 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 Dated with the understanding that the Owner and/or any, Subsequent Owner will •operate the. Sewage.. Disposal System in Accordance with the Sewage Handling and Disposal Regulations of the Virginia Department of Health and any:Variances or Conditions Granted. 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 ❑ NONEXX ❑ SEE ATTACHED YY0 .NONE. ❑ SEE ATTACHED March 25, 1993 Effective Date RecVmended a itarian) Approved (State Health Commissioner) C.H.S. 05 Rev. 4/83 - F \ s Sewage Disposal System Construction Permit PAGE_lOF— Commonwealth of Virginia Health Department 101-92-0300 Depaetigg�ttofiHeelth., - Identification Number ?g_20 Health Department Map Reference - General information New ❑x Repair ❑ Expanded ❑' Conditional ❑ FHA ❑ VA ❑ Case No. Based on the application for a sewage disposal system construction permit filed in accordance with Section 3.13.01, a construction permit 's ereby issued to: ^+FLL> M. 1J B INuud 703-943-6893 Owner r: Telephone Address ' o- , Ux mu N, VA 644o For aType—_WEjj_0, ewNjge $ sposal system,i,bs, constructed on/at nitichliRV Subdivision < Section/ 1,ock Lot Actual or estimated water use Y�� rU 3 �cd 0oms, DESIGN NOTE: INSPECTION RESULTS Water supply, existing: (,describe) Water ,supply location: Satisfactory yes [DI no Elilia comments I K*r%A4 �_10 I93 . G. W. 2 Received: ,yes p%no ❑ not applicable ❑ . To be installed: class 11IC cased 20 FT. grouted 20 FT. Building sewer: Building sewer: yes ®/ no ❑ comments 4 I.D. PVC-40, or equivalent. 'Satisfactory Slope 1.25" per 10' (minimum). ❑ Other Septic tank: Capacity 900 gals. (minimum). Pretreatment unit: yes p/ no ❑ comments ❑ Other Satisfactory Inlet -outlet structure: Inlet -outlet structure: yes Q/ no ❑ comments PVC 40, 4" tees or equivalent. Satisfactory ❑ Other Pump Ind pump station: Pump & pump station: yes ❑ no ❑ comments, No ❑ X Yes ❑ describe and show design.��--�^'-` if yes: �- ✓� /y Gravity mains: 3F or larger I.D.,, Ar 'yes ❑ono ❑ comments 1001, 1500 lb. crush strength or e' 'k ❑ Other Distribution box: �O� �`' !(as no ❑ ❑ comments Precast concrete with 5 ports . ` ' ❑ Other I Header lines: es no ❑ comments Material: 4" I.D. 1500 lb. crush strengt lent from distribution box to 2' into Slope 211 minimum. �iO �1 / n Other ` 11p Percolation lines: is 0,"no ❑ comments Gravity 411 plastic 1000 lb. per foot equivalent, slope 2" 4" (min. max.) per I ❑ Other Absorption trenches: r.Ton,venches: yes p no ❑ comments Square ft. required :22�g depth from group- d`surface Satisfactory to bottom of trench An" ; aggregate size _cam? " Trench bottom slope _g *" /Inn VT ; to spacing ^ -; trench width ? ^' i 2(p �(Q�{ %,� A center center E Date Inspecfed and approved by: Depth of aggregate ice„ Trench length �.^n' ; Number of trenches ^ � Sanitarlan C.H.S. 202A Revised 6184 II.2 0 Sewage Disposal System Construction Permit PAGE OF Commonwealth of Virginia Health Department- 101-92-0000 Depa�tt12g�1totiHealth, f�� _e�1 Identification Number ?9-on-Ar- Health Department Map Reference r General Information New ❑x Repair ❑ Expanded ❑' Conditional ❑ FHA ❑ VA ❑ Case No. Based on the application for a sewage disposal system construction permit filed in accordance with Section 3.13.01, a construction permit is ereby issued to: Mis"1B M. uOUAINUUd - 703-943-6893 Owner Telephone Address , o-A, ux nu A, VA caeo For a Type 0.Sewttsge gisposal system ,hinc1hlisAo M cocnstructed on/at Subdivision t> < 5 Section/.Block Lot Actual or estimated water use Y�� �3 ' 6'.A'O°rn%. DESIGN NOTE: INSPECTION RESULTS Water supply,- existing: (describe) Water ,supply location: Satisfactory yes non ❑ tiff ( comments IWr- 4 %Zln ki3 G. W. 2 Received: ,yes 19_�no ❑ not applicable ❑- To be installed: class [IIC cased 20 FT. grouted 20 FT. Building sewer: I Building sewer: yes. W/ no ❑ comments 4 I.D. PVC-40, or equivalent. 'Satisfactory Slope 1.25" per I (minimum). ❑ Other Septic tank: Capacity 900 gals. (minimum). PretreatmentunR:. yes pp� no ❑ comments ❑ Other Satisfactory Inlet -outlet structure: Inlet -outlet structure: yes no ❑ comments PVC 40, 4" tees or equivalent. Satisfactory ❑ Other Pump a d pump station: Pump 6 pump station: yes ❑ no ❑ comments. No O Yes ❑ describe and show design. Satisfactory ((�P if yes: Gravity mains: 3F .or larger I.D.,, minimum 6". fall per Conveyance method: yes 121�no ❑ comments 1001, 1500 lb. crush strength or equivalent. - Satisfactory - - ❑ Other Distribution box: Distribution box: yes E" no ❑ comments Precast concrete with ports. Satisfactory ❑ Other Header lines: Header lines: yes 0 no ❑ 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. 1- Other Percolation lines: Percolation lines: yes 0/no ❑ comments Gravity 4" plastic 1000 lb. per foot bearing load or Satisfactory equivalent, slope 2" 4" (min. max.) per 100'. p Other , Absorptiontrenches: Absorption trenches: yes no ❑ comments Square ft. required .299 : depth from ground surface Satisfactory to bottom of trench An" ; aggregate size�� Trench•bottom slope 4 *"'Inn vm center to center spacing n ;trench width n' % �(o (� fl - Date 1�Q Inspected and approved by; Depth of aggregate ��„ � , Vj' (tip Trench length ^^' ; Number of trenches 1 Senitarlen , C.H.S. 202A Revised 6/84 11.2 Health Department a Identification Number I OI' 92 - O 3c Schematic drawing of sewage disposal system and topographic features. , PAGE 2 OF 2 Show the lot lines of the building 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. Q The information required above has been drawn on the attached copy of the sketch submitted.with the application. Attach additional sheets as necessary to illustrate the design. 2la_" -- i( I° lCtEl' L Dina L 7 I 2P_'-�_p oC4 E:+ 2 I The sewage disposal system is to be constructed as specified by the permit 'Q' or 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. 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 uncov- ered; if necessary, upon the direction of the Department. Date: 7 Issued by:� This Construction / Sanitarian ,t `ali until Date: `l< ��1�- Reviewed by:✓� Supervisory Sanitarian -----------------------------q_-__________-----_ If FHA or VA financing _ Reviewed by Date C.H.S. 202B Revised 61a< Supervisory Sanitarian 11-2A Date Regional Sanitarian M ALBEMARLE COUNTY HEALTH DEPARTMENT P. O: BOX 7546 CHARLOTTESVILLE, VA 22906 July 17, 1992 NELLIE M. GOCHENOUR RT. 1, BOX 145-A CRIMORA, VA 24431 DEAR NELLIE M. GOC'HENOUR: RE: tiD iLs lul-'lZ-Usuu Any water well installed in Virginia mast meet specfic construction stanaards before final approval of the water system ( will be given, or an occupancy permit can be obtained. i +- They are as follows: 1. Your well must be cased ana grouted 20 feet minumun unless otherwise designated. 2. Your well must be located at least l0u feet from any drainfield and any cnemically treated foundation, also iv feet from any property line. 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 Heaith Department with the Construction Permit Id number. Contact your iocai heaitri 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 caii 804-972-6200. Sincerely, �. G. Stephen Rice Environmental Heaith Specialist i' � it � �. � ., Soil Evaluation Form PAGE 1 OF ` Commonwealth of Virginia Health Department 101-92-0300 Department Of Health Identification Number Tax Map Number 26-20 General Information Date 07/14/92 ALBEMARLE CO. Health Department Applicant SEE ATTACHED APPLICATION Telephone No. Address Owner NELLIE M. GOCHENOUR Address RT. 1, BOX 145-A, CRIMORA, VA 24431 Location WEST OF RT. 674 .2 MILE NORTH OF RT. 614 Subdivision Block/Section Lot Soil Information Summary 1. Position in landscape satisfactory Yes �Z' No ❑ Describe 'Sbvgu 2. Slope B % 3. Depth to rock/impervious strata Max. Min. 60 None 4. Depth to seasonal water table (gray mottling or gray color) No ❑ XXeS ❑ inches 5. Free water present No ❑ XYes ❑ range in inches 6. Soil percolation rate estimated Yes ❑ X'Jexture group I II 11 IV No ❑ Estimated rate _54 min/i ch 7. Percolation test performed Yes ❑ Number of percolation test holes No ❑ XQepth of percolation test 17gles Average percolation rate � Name and title of ala F a, Stephen Rice, SANITARIAN Signature: (/J� V Department Use Nf9ite Approved: Drainfield to be placed at _depth at site designated on permit ❑ Site Disapproved: Reasons for rejection: 1. ❑ Position in landscape subject to flooding or periodic saturation. 2. ❑ Insufficient depth of suitable soil over hard rock. 3. ❑ Insufficient depth of suitable soil to seasonal water table. 4. ❑ Rates of absorption too slow. 5. ❑ Insufficient area of acceptable soil for required drainfield, and/or Reserve Area. 6. ❑ Proposed system too close to well. 7. ❑ Other Specify C.HS.201A Rev.n 4/87 v-t Date of Evaluation n_?,/1419 - Profile Description Health Department SOIL EVALUATION REPORT Identification No 101 92-020�0 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. O See application sketch ❑ See construction permit Xsee sketch on reverse side or page attached to this form. I Hole # I Horizon I Depth (Inches) I Description of, color, texture, etc. I Texture Group I Remarks crsm's n.,..e.1e1 V-1A u OWNER'S NAME: NELLIE M. GOCHENOUR 101* 2-0300 SAN. NAME: G. Stephen Rice DATE: 7 iq SYSTEM TYPE 1 DIRECTIONS: WELL TYPE Wd,+ aI ►2, �7� TRENCH DEPTH .�� 2 Ih4�l NOV4 NO. OF TRENCHES 4 DEPTH TO ROCK -jj-Q' / LENGHT OF TRENCHES I�%DEPTH TO WATER TABLE i SLOPE 8� DEPTH'TO rtFREE' WATER NA PERK RATE TEXTURE GROUP . PUMP LETTER INFO Lift.p MAIL TO Gals ff�� SOIL INFORMATION' DESCRIPTION TEXTURE GR. .d Iwm_�1�4�Z- I , 44yLO"N/m ne, �� mahtl�elw�� y ,r 2. -A 6-`g _t gloc uYDW Y1 I04M T C_ B �- youi %I,n '9,,L -Ito r. 1 I_ n^�I r 9l+ `-- SEE BACK FOR SKETCH - l .'Application for a.Sewage.Disposal System Construction -Permit Commonwealth of Virginia For Department Use Only Health Department .Department of Health Identification Number f``. Map Reference f -�i Health Department: - Date Received ipU-1 To Be Completed By The Applicant >. . Type sewage. system:, ; pINew - - ❑ Repair • ❑ Expanded ❑ Conditional . FHA/VA yes ' no - ❑ Owner/.: ; (/, ) )... .. sr.r Address /-Si, A-21-I <_ Pho ery Agent Directions to Property,/ `L Address . Phone .— t=:'i Subdivision. Section Block Lot - :.Other, Property Identification. .T) i =+ lr. • i�cr' �' % -; -)( I' J �'1 Dimensions/size of Lot/Property, Other Application Information.: _ 1. Building/facility `: CI -New Intermittent: Use ❑ Yes B. Residential Use Q.yes Termite Treatment p"Yes ❑D Single Family Basement p'Yes Fixtures In Basement ❑ Yes 111. Commercial Use ❑ Yes Commercial/Wastewater ❑ Yes If yes, give volumes and describe . IV. Water Supply: V. Proposed Installation: If other. describe — ❑ Existing E],No If yes,- describe: ❑ No ❑ No ❑ Multifamily Number of Units ^. Number of Bedrooms —� ❑ No ❑ No No Describe: El, -No Number of Patrons Number of Employees ❑ Public ©' New Describer/ /r p'Private ❑ Existing — 0 Septic 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 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 owner/agent Date THOMAS JEFFERS03 HEALTH DISTRICT Imoortant Notice PLEASE READ BEFORE FUNG YOUR APPUCATICN AND PAYING YOUR FEE This is to inform ytu 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 sanitarian makes a site visit to evaluate the property and if a refund is requested by the applicant. or 2. The Health Department is unable to issue a permit and only then if (a) you own the lot and 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 ycu are foregoing your right to appeal the denial of your request for a permit. In order for you to then appeal at a later date, the above refunded fee.would need to be reinstated before a hearing date would be scheduled. 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 aoply;,for a Health Depart:aent permit when you know where you want to build. It is vour resoonsibility to have the corners or prooerty lines of a lot .clearly marked and to have the four corners of the oraoosed house site flaaced. The sanitarian will —not he able to comoiete work without these markings. He may refuse to oer'oro the soil stud,/ if this has not been done. Also if the lot is too overgrown then the sanitarian may require bushhcgging, etc.,' before site work can be done. It is also your responsibility to make it clear to the sanitarian 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 chanced iater without additional expense om vour oar-. If this occurs, you will need to hire a private sail consultant to test another site and submit his reoort, along with a new adplication and fee to. the health deoar-meat. I have read and understand the above acolication notice. - Signature pp icant Date . ,AV, 1 Test Requested: Results: cc: Coliform, drinking water Coliforms absent Albemarle County Health Department If you have any questions as to the meaning of your test results, please contact me or the Biotechnology Division Laboratory. Please let us know if we can be of any further service to you. i Pamela E. Bell, PhD Director, Biotechnology Laboratory 14' Mar.22 '93 8:49 1234 R.A. iIGHTNER TEL 7M-234-e628 P. 1 Vt•Ql a fmt Record Of Inspection —Nonpublic Drinking Water Supply System Commonwealth of Virginia Department of Health F.H.A. or V.A. Case Number If Applicable Date Owner Use of form required only when water supply constructed in con- junction with an on -site sewage disposal system, or when FHA, VA financing is involved. Local Health Department Health Department9'L-0300 I.D. Number ALBEMARLE CO. Map Reference 7G ZO g (B NELLIE M. GOCHENOIA°ddress. RT. 1, BOX 145-A Phone 43-6893 -RA- Exact'Location of Premises ( d) 12A Ndrth A 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) ❑ 2 ` j• /`� � 4) Class III D. (dug well) El Date of installation 5) Other E. _ ❑ CONSTRUCTION INFORMATION If information in any item below is secured from other sources well log)etc., so note. 1. Water well completion report filed as required by 18.02.01: (i.e.,es pJNo .❑ 2. Well Location: Distances from sources -of pollution (see Table 12.1, Minimum Separation Distances) and Section 10.04.01 and 18.02.02. 1 Building Sewer ` )� Pretreatment Unit — `�+ Conveyance System /nl Subsurface.. Soil Absorption System 100'f (nearest point). Property Line —10 Other Site graded where necessary to divert water away from well? Yes El ❑ No n.a. 3. Construction, General: (see Section 18.02.05, and 18.02.02) Total depth of well . 236 feet. Type of casing P1C. Depth of casing 2b feet. Diameter of casing _ _A liq inches:. Casing extenc(s inches above ground 12 ' . Exterior space around casing sealed with neat cement grout to a depth of 20 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 5W5 Pitless adapter used? yes 2. 'no ❑ n.a. ❑ Properly installed? yes.21 no ❑ n.a. ❑ Proper venting? yes ❑ no ❑ n.a, j]' 4. Quantity: Yield and drawdown determined by continuous pumping of hours. Drawdown feet. Yield GPM. Type of storage �0 �✓ 5. Quality: Sample tap provided at entry into system? yes ❑ no ❑ Sample(s) collected? yes [/ no ❑ Results of samples. Satisfactory z 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. 211 Date Date C.H.S. 204 Rev. 4/e3 Signed Signed Signed Supervisory Sanitarian Regional Sanitarian (If V.A. or F.H.A.) PERMIT I.D. NO. /a� .��- °0 42 TAX MAP: In - Ad r 9(o NAME: Initials Date Application Received: Application Reviewed: Fee Determined: Assigned to: Site Visit Scheduled: C Site Visit Made: Follow-up Visit: Follow-up Visit: �i 51'L Issue/Deny Drafted: • ��%�� L Z. Issue/Deny Reviewed: ... sue/D ny Countersigned: Issue/Deny Mailed: I � i I Owner Phone — Location General Inforrnat' Drilling Method o Y Depth to Bedrock Static Water Level 1 Well. Disinfected (Y or N) casing From er �'6 Size I. Material Weight/S adule o Gravel Pack From To Grout Z From To Bore Hole Sized /T Type Method Water Zones or Screened Intervals Commonwealth of Virginia m Water Well Completion Report Well Data Date Completed Yield 4. (GPM)) Stabilized Water Level C� b Disindectant Used From To Size Material ) Weight/Schedule Tax Map ID — g D VDH Permit VWCB Permit VWCB ID County Total Depth of Well rzo Length of Test o ,a ' Natural Flow (Rate) ' Arnourit'Used j�Ti� From To Size Material `Weight/Schedule From To From To From Bore Hole Size Type Method _ To From Toy Bore Hole Size From To From To From To Mesh Size Diam Mesh Size Diam Mesh Size Diam From To From To From To Mesh Size Diam Mesh Size Diam Mesh Size Diam L' • Use Data Private Well: Domestic Agricultural _ Industrial _ Monitoring Public Well: Community= Non'Community I I - Abandonment Information Bored or Dug Wells Casing Removed, Y or N?:_ It Y, Depth to which casing was removed:_ Depth and Type of Fill: Source of Fill ' Bentonhe Plugs: From —to From —to — Method of permanently marking nN " Wells other than Bored Wells Casing removed, Y or N? _ Depth to which casing was removed:_ Applicable, depth(s), and type of gravelfsand (ill: Source of gravel or sand: Cement: From _ to _ From _ to _ Depth Drillers Log Description of Formation or Sediment �E� RWE FEB 10 1993 TJH® E.H, Ira 11 (User additional Sheets if necessary) I certify that the information contained here is true and that this well was installed and constructed in accordance with the permit and further that the well complies with all applicable state and local regulations, ordinances and laws. NameHALL WELL & PUMP COMPANY Address Phone Drillers Date rA Virginia Contractors License Number n c) I Ty C� S A letion Statement M State Department of Health Health Department Identification Number 101'92-M Albenrerle Health Department Name of Company/Corporation/Individual: 'Rob*E A l i4tn= Exsav=N, ins Address: P.O. Box 2 Weems Cave, VA 24486 Telephone: 7m/234_8554 Owner's Name Nellie Goclxn Owner's Address Rt. 1, Box 145-A amnia, VA 24431 Location of Installation: Lot Section: Subdivision: Other: West of Rt. 674 .2 ndle north of Rt. 614 Block I hereby certify that the onsite sewage disposal system has been installed and completed in accordance with the con- struction permit issued (date) 7/17/92 and is in compliance with Part D of the Sewage Handling and Disposal Regulations and when appropriate the plans and specifications for the project. 3/17/93 \A� a(// Date Signature and Title C.H.S:.2`03 R. //83 ` - -� _ _