Loading...
HomeMy WebLinkAboutSUB202300050 Assessment - Groundwater 2023-03-23AOSE/PE Inspection Report and Completion Statement Commonwealth of Virginia State Department of Health Name ofAOSE/PE: Tom Health Department Identification Number: /0I'Z2-01 (% Tax Map: & -1 Y A 19146EmarhPi Health Department Certification Number: 1940 001091 Address. PO BOX 418, Ruckersviille, VA 22968 Telephone: (434) 985-2780 Contractors Name -9i-O Ck G, b.�On Owner's Owner's Location of Inssttalllation Subdivision: Section: Block: Lot Other: Tip. Q(p '111/4 Inspection Results Component Comments, Materials, Etc. Deficiencies Observed, Date Deficiencies Observed Corrective Action Required Date Approved Water Supply Location and Construction%A/p// a/ / hO� �r•///e G! (7j OF $'/9 Z2— 'ems Building Sewer yo 7rf 8 /9 2 Septic Tank _ /� ' O 00 Inlet -Outlet Structure r a %rl � on � �/ P✓G 7�S /9 2 Z Pump and Pimp Station ,p /U to vrn l Conveyance Method II `70 PI/G ib box gJ 9 2 2- Distribution Box or Pressure Manifold y S Co nc-r . d —�r twl /e V(J ll(j%_ S )9 Z Header, Conveyance, Return, etc. Lines c Y Percolation Lines, Drip, Chambers, etc. Absorption Trenches and Dispersal Field (Other Components: treatment unit etc.) Attach observed deficiencies and corrective actions taken on a separate completion statement as necessary. AOSETE Completion Statement: As -Built Drawing Commonwealth of Virginia State Department of Health Health Department Identification Number: © I — ZZ- ©' 1 6 Tax Map: t✓ T Triangulate critical system components to fixed reference points. 15 yap A c TT' B-c � J� ❑ Check here if as -built drawing is on a separate page attached to this form (Attachment must display Health Dept. Identification Number, tax map number, and most be signed and dated by AOSE/PE). 1 hereby certify that on 6 ` r / ` 2 (date), I, or an employee under my direct supervision, inspected this sewage system's construction. The onsite sewage system has been installed and completed in accordance with the construction permit issued on k— �%—%) _ (date) and is in compliance with the Sewage Handling and Disposal Regulations (12 VAC 5-610 et seq), Private Well Regulations (12 VAC 5-630 et seq), when applicable, and the plans and specifications for the project. AOSE/PE G. AOSE Form BB: Revised 0428/06 Date: lJ