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VIRGINIA
Albemarle County Health Department
PO BOX 7546
DEPARTMENT
VDH
Charlottesville, VA 22906
OF HEALTH
(434)972-6219
Protecting You and Your Environment
(434) 972-4310 Fax
PE Sewage Disposal System Construction Permit Letter (COV32.1-163.6
, 2016
Canaan Christian Church
st
3045 1
3045 Ivyy Road
Charlottesville, VA 22903 Approved
RE: Tax Map: 80-21
HDID: 101-16.0360 Reserve: 100% reserve area provided
System Capacity: Non -Residential, 550 gallons per day
Dear Canaan Christian Church
This letter and the attached drawings, specifications and calculations dated May 22, 2016 constitute
your permit to install a sewage disposal system on the property referenced above. Your application for a
permit was submitted pursuant to §32.1-163.6 of the Code of Virginia, which requires the Virginia
Department of Health (VDH) to accept designs for onsite sewage systems from individuals licensed as
Professional Engineers (PEs). This law allows PEs to design onsite sewage systems that do not fully
comply with the Sewage Handling and Disposal Regulations (12 VAC 5-610-10 et seq.) and requires
VDH to accept such designs provided they comply with standard engineering practices, performance
requirements set by the Board of Health, and certain horizontal setback requirements necessary to protect
public health and the environment. VDH hereby recognizes that the design submitted by Roderick F.
Pierson, P.E. complies with the requirements of the Code of Virginia and the Regulations for
Alternative Onsite Sewage Systems and grants permission to install the system as designed in the area
shown on the attached plans and specifications.
If modifications or revisions are necessary between now and when the system is constructed, please
contact the PE who designed the system upon which this permit is based. Should revisions be necessary
during construction, your contractor should consult with the PE. The PE is authorized to make minor
adjustments in the location or design of the system provided that adequate documentation is provided to
the Albemarle County Health Department.
The PE that submitted the design for this permit is required by the Sewage Handling and Disposal
Regulations to conduct a final inspection of this sewage system when it is installed and to submit an
inspection report and completion statement to the Albemarle County Health Department. The health
department is not required to inspect the installation, but may do so at its sole discretion. The sewage
system may not be placed into operation until you have obtained an Operation Permit from the Albemarle
County Health Department. If your PE did not submit an Operation and Maintenance Manual for review
and approval with the plan package, then (s)he will be required to do so prior to issuance of an Operation
Permit.
Tax Map/GPM: 80-21
HDID: 101-16-0360
Page 2 of 3
This Construction Permit is null and void if site and soil conditions are changed from those shown on
your application or if conditions are changed from those shown on the attached plans and specifications.
VDH may revoke or modify any permit if, at a later date, it rinds that the system would threaten public
health or the environment.
This permit approval has been issued in accordance with applicable regulations based on the
information and materials provided at the time of application. There may be other local, state, or federal
laws or regulations that apply to the proposed construction of this onsite sewage system. The owner is
responsible at all times for complying with all applicable local, state, and federal laws and regulations. If
you have any questions, please contact me.
This permit expires February 25, 2018. This permit is not transferable to another owner or location.
Sincerely,
z
Josh Kirtley
Environmental Health Technical Specialist
Cc: Pierson, Roderick F., P.E.
Tax Map/GPIN #: 80-21
HD1D#: 101-16-0360
WHAT YOU WILL NEED TO GET YOUR
SEPTIC SYSTEM OPERATION PERMIT
Page 3 of 3
• Your system must have a satisfactory inspection at the time of installation. This will be done by the
designer of your permitted system, a private OSE or PE. Your OSE or PE must submit a copy of the
inspection results, complete with an as -built diagram, to the Health Department.
• Please ensure that your contractor turns in a Completion Statement to the local Health Department after
installation.
• If your permit is for an alternative system, you must sign, have notarized, and record the attached Notice
of Recordation in your locality's land records. Please bring proof of this recordation to the local Health
Department
Allow 5 business days after the last piece of documentation is received for the Operation Permit to be
issued. To avoid delays, clearly label each*piece of documentation with the property Tax Map number
and HDID number shown above and on your construction permit. Please note that due to the individual
circumstances of your permit there may be additional required items not covered by this checklist.
If you have any questions about any of the items on this list, please do not hesitate to contact the
Albemarle County Health Department at (434) 972-6219.
Page] of 2
V'DHVIRGINIA Albemarle County Health Department
DEPARTMENT PO BOX 7546
OF HEALTH Charlottesville, VA 22906
Protecting You and Your Environment (434) 972-6219
434
Private OSE Private Well Permit
May 06, 2016
Canaan Christian Church
3045 Ivy Road
Charlottesville, VA 22903
Tax Map #: 80-21 HDID: 101-16-0190
860 Hacktown Road
Keswick, VA 22947
Dear Canaan Christian Church:
This letter, in conjunction with the approved plans and specifications, which are attached, constitutes
your permit to install a private well. The application for a permit was submitted pursuant to
§32.1-163.5 of the Code of Virginia which requires the Health Department to accept private site
evaluations and designs from an Onsite Soil Evaluator (OSE) or a Professional Engineer working in
consultation with an OSE for residential development. The permitted site was certified as being in
compliance with the Board of Health's Private Well Regulations (12VAC5-630-10 ets seq.), and local
ordinances if the locality has authorized the local health department to accept private evaluations for
compliance with local ordinances, by Thomas Graham Hogge, Private OSE #1940001091.
This letter is issued in reliance upon that certification .The Board of Health hereby recognizes that the site
conditions acknowledged by this correspondence, and documented by additional records on file at the
local health department, are suitable for the installation of Private Well. The attached plat (or plats)
shows the approved areas for the private well. This letter is void if there is any substantial physical
change in the soil or site conditions where a sewage disposal system is to be located.
If modifications or revisions are necessary between now and when you construct your dwelling, please
contact the Onsite Soil Evaluator (OSE) or Professional Engineer (PE) who performed the site evaluation
and design on which this private well permit is based. The name, address, and phone number of the
OSE/PE appears on the certification form attached to this permit. Should revisions be necessary during
construction, your contractor should consult with the OSE/PE that submitted the site evaluation or site
evaluation and design. The OSE or PE is authorized to make minor adjustments in the location or design
of the system at the time of construction provided adequate documentation is provided to the Albemarle
County Health Department.
This authorization is null and void if conditions are changed from those shown on the application or
conditions are changed from those shown on the attached construction drawings, plans and
specifications.
Tax Map M 80-21
HDID: 101-16-0190
Page 2 of 2
No private well shall be used until inspected, corrections made if necessary, and approved by the
Albemarle County Health Department or unless expressly authorized by the Albemarle County Health
Department. Any part of any installation which has been covered prior to approval shall be uncovered if
necessary, upon the direction of the Department. If you have any questions, please contact me. This
authorization to construct a private well expires: November 04, 2020.
Sincerely,
J,4-: J. OL
Travis T. Davis, OSE
Environmental Health Specialist, Sr.
cc: Thomas Graham Hogge
Page] of 2
V'DHVIRGINIA Albemarle County Health Department
DEPARTMENT PO BOX 7546
OF HEALTH Charlottesville, VA 22906
Protecting You and Your Environment (434) 972-6219
434
Private OSE Private Well Permit
May 06, 2016
Canaan Christian Church
3045 Ivy Road
Charlottesville, VA 22903
Tax Map #: 80-21 HDID: 101-16-0190
860 Hacktown Road
Keswick, VA 22947
Dear Canaan Christian Church:
This letter, in conjunction with the approved plans and specifications, which are attached, constitutes
your permit to install a private well. The application for a permit was submitted pursuant to
§32.1-163.5 of the Code of Virginia which requires the Health Department to accept private site
evaluations and designs from an Onsite Soil Evaluator (OSE) or a Professional Engineer working in
consultation with an OSE for residential development. The permitted site was certified as being in
compliance with the Board of Health's Private Well Regulations (12VAC5-630-10 ets seq.), and local
ordinances if the locality has authorized the local health department to accept private evaluations for
compliance with local ordinances, by Thomas Graham Hogge, Private OSE #1940001091.
This letter is issued in reliance upon that certification .The Board of Health hereby recognizes that the site
conditions acknowledged by this correspondence, and documented by additional records on file at the
local health department, are suitable for the installation of Private Well. The attached plat (or plats)
shows the approved areas for the private well. This letter is void if there is any substantial physical
change in the soil or site conditions where a sewage disposal system is to be located.
If modifications or revisions are necessary between now and when you construct your dwelling, please
contact the Onsite Soil Evaluator (OSE) or Professional Engineer (PE) who performed the site evaluation
and design on which this private well permit is based. The name, address, and phone number of the
OSE/PE appears on the certification form attached to this permit. Should revisions be necessary during
construction, your contractor should consult with the OSE/PE that submitted the site evaluation or site
evaluation and design. The OSE or PE is authorized to make minor adjustments in the location or design
of the system at the time of construction provided adequate documentation is provided to the Albemarle
County Health Department.
This authorization is null and void if conditions are changed from those shown on the application or
conditions are changed from those shown on the attached construction drawings, plans and
specifications.
Tax Map M 80-21
HDID: 101-16-0190
Page 2 of 2
No private well shall be used until inspected, corrections made if necessary, and approved by the
Albemarle County Health Department or unless expressly authorized by the Albemarle County Health
Department. Any part of any installation which has been covered prior to approval shall be uncovered if
necessary, upon the direction of the Department. If you have any questions, please contact me. This
authorization to construct a private well expires: November 04, 2020.
Sincerely,
J,4-: J. OL
Travis T. Davis, OSE
Environmental Health Specialist, Sr.
cc: Thomas Graham Hogge