HomeMy WebLinkAboutSUB201600074 Approval - Agencies 2016-08-01 . . r
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COMMONWEALTH of VI 1''QINI[A
In Cooperation with the Thomas Jefferson Health District ALBEMARLE-CHARLOTTESVILLE
State Department of Health FLUVANNA COUNTY(PALMYRA)
1138 Rose Hill Drive GREENE COUNTY(STANARDSVILLE)
LOUISA COUNTY(LOUISA)
Phone(434)972-6219 P.O. Box 7546 NELSON COUNTY(LOVINGTON)
Fax (434)972-4310
Charlottesville,Virginia 22906
8/1/2016
County of Albemarle
Department of Community Development
401 McIntire Road,Room 227
Charlottesville,VA 22902
RE: Review of Proposed Subdivision Plat as part of Tax Map 121,Parcels 9 and 9C,located
in Albemarle County,Virginia.
To Whom it May Concern:
On July 28,2016,the County of Albemarle requested the Virginia Department of Health(via the Albemarle
County Health Department)review the proposed subdivision plat identified above.This letter is to inform you
that the above referenced subdivision plat is approved for individual Onsite Sewage Systems in
accordance with the provisions of the Code of Virginia,the Sewage Handling and Disposal Regulations,
and local ordinances.
This request for subdivision review was submitted pursuant to the provisions of§32.1-163.5 of the Code of
Virginia which requires the Health Department to accept private soil evaluations and designs from an
Authorized Onsite Soil Evaluator(AOSE)or a Professional Engineer working in consultation with an AOSE for
residential development. This subdivision was certified as being in compliance with the Board of Health's
Regulations by:Jason Kyser,private OSE,License Number 1940001357. This subdivision approval is
issued in reliance upon that certification.
Pursuant to§360 of the Regulations this approval is not an assurance that Sewage Disposal System
Construction Permits will be issued for any lot in the subdivision identified above unless that lot is specifically
identified on the above referenced plat as having an approved site for an onsite sewage disposal system,and
unless all conditions and circumstances are present at the time of application for a permit as are present at the
time of this approval. This subdivision may contain lots that to do not have approved sites for onsite sewage
systems.
This subdivision approval does pertain to the requirements of local ordinances.
Sincerely,
S -'- ' g .---st ( 0
Environme tal flea th Specialist,
Onsite Se age and Water Programs •
FAT Ve
I spy
COUNTY OF ALBEMARLE �-
Department of Community Development c,\) e I �`
401 McIntire Road,Room 227 �� ,p n nom"
Charlottesville,Virginia 22902-4596 W`'"e7''
Phone(434)296-5832 Fax(434)972-4126
July 28, 2016
Teresa Batten
Virginia Department of Health
1138 Rose Hill Drive
Charlottesville,VA 22906
RE: SUB201600074 Jefferson Area Builders-BLA
Dear Ms. Batten:
The County of Albemarle has received application to develop/subdivide[Tax Map 121,Parcels 9&9C]. This project
requires Health Department approval before receiving final County approval. The applicant has provided soils
information,which is attached. Please review the proposal for suitable subsurface drainfields which comply with the
provisions of Chapter 18,Sections 4.2.2,4.2.3,4.2.4,and Chapter 14, Sections 14-309 and 14-310 of the Albemarle
County Code. Should you have any comments please feel free to contact me.
Sincerely,
5 A
P ��tySate
Senior Planner
Department of Community Development
Voice: (434)296-5832 ext. 3250
Fax: (434)972-4035
LI An1rL Page of ir
OSE/PE Report for:
Construction Permit F Certification Letter 11 Subdivision Approval
Property Location:
911 Address: City:
Lot Section Subdivision
GPIN or Tax Map# It I posirc.E.1 9 Health Dept ID#
Latitude Longitude
Applicant or Client Mailing Address:
Name: 4,_,leo 5ndJee
Street: 5 4ri+jra./j 7;A/we ' 5:41)1.e. /00
City: CNS Io*ksv;/L. //4 State (/4 Zip Code Z,Z/O
Prepared by:
OSE Name g; rharuct y; ein,,,M,L, t-1.4. y3y-zin-oz7; License# /?'Moo/3r 7
Address r;. go x 75-s /
City / e 3 WiG� State chi Zip Code ZZ,'`/7
PE Name: License#
Address
City State Zip Code
Date of Report 07/IS/2o14 Date of Revision#1
OSE/PE Job# Date of Revision#2
Contents/Index of this report(e.g.,Site Evaluation Summary,Soil Profile Descriptions,Site Sketch,Abbreviated Design,etc.)
fA%` 3-y_S!k ,,,/vs r�, le, s
P7` r-4 Pesr, 6•15 ; zLLr.v.A04i157,,
174- 7 $y5/. . 5/,«,-A-..h, s
Certification Statement
I hereby certify that the evaluations and/or designs contained herein were conducted in accordance with the Sewage Handling and
Disposal Regulations(12 VAC5-610),the Private Well Regulations(12 VAC5-630)and all other applicable laws,regulations and
policies implemented by the Virginia Department of Health. I further certify that I currently possess any professional license required
by the laws and regulations of the Commonwealth that have been duly issued by the applicable agency charged with licensure to
perform the work contained herein.
t fhe work attached to this cover page has been conducted under an exemption to the practice of engineering,specifically the
exemption in Code of Virginia Section 54.1-402.A.11
I recommend that a(select ): c nstruction permits certification letter subdivision approval E— "
be(select one)issued denied Li.
OSE/PE Signature DateO7//S/o/C
-
j
?wic z el. S
Commonwealth of VirginiaVDH Use only
Health Department ID#
Application for: ewage System Cater Supply Due Date
Owner /litehLr4` s; )//r Phone q3'l-29L- 9Y/9
•
Mailing Address X1520 G►i.u..,.t-e-I ..f.� u.e 5..►f e. /0,6 Phone
(j hrtl/nl•}a5vi l!ie/ VH 72 9O/ Fax
Agent /0,-.L.41! .50,114, Phone Ii3Y-274 - ?//9
5y� lx
Mailing Address R ls r'e/1 � ,•...5;.:1-c iiRt# fO6 Phone
(/L0ll.j. t,ilIe 0 22901 Fax
Site Address
Email
L,..1,Directions to Property: /Verl•l,s,Jz .„1tC a,.�.Je 7/S i �/ 51 S' oe 4tiiL wie 7/`/
Subdivision Section Block Lot
Tax Map 12! p jti 17 Other Property Identification Dimension/Acreage of Property 3.L3Oracris
-Sewage System
Type of Approval:Applicants for new construction are advised to apply for a certification letter to determine if land is ----
suitable for a sewa3e system and to apply for a construction permit(valid for 18 months)only when ready to build.
0Certification Letter Q Construction Permit 0 Voluntary Upgrade 0 Repair Permit
Proposed Use:
Single Family Home(Number of Bedrooms 3 ) Multi-Family Dwelling(Total Number of Bedrooms )
Other(descnb )
Basement?Bles0No Walk ut Basement bNo Fixtures in Basement - esONo
Conditional permit desired?0Yes , iWoo If yes,which conditions do you want?
['Reduced water flow ['Limited Occupancy 0 Intermittent or season use ❑Temporary use not to exceed 1 year
Do you wish to apply for a betterment loan eligibility letter' Yes -. o *There is a$50 fee for determination of eligibility.
Water Supply
Will the water supply beOPublic or 'vate? Is the water supplyDExisting o roposed?
If proposed,is this a replacement well?QYes IBNo If yes,will the old wel a abandoned?DYes ONo
Will any buildings within 50'of the proposed well be termite treated?DYes 10
Al!Applicants
Is this a private sector OSE/PE application? es ONo If yes,is the OSE/PE package attached? --. es ONo
Is this property indeed to serve as your(owners)principal place of residence?Dyes EittrCr
In order for VDH to process your application for a sewage system you must attached a plat of the property and a site sketch. For water
supplies,a plat of the property is recommended and a site sketch is required. The site sketch should show your property lines,actual and/or
proposed buildings and the desired location of your well and/or sewage system. When the site evaluation is conducted the property lines,
building location and the proposed well and sewage sites must be clearly marked and the property sufficiently visible to see the topography.
I give permission to the Virginia Department of Health to enter onto the property described during normal business hours for the purpose of
processing this application and to perform quality assurance checks of evaluations and designs certified by a private sector Onsite Soil
Evaluator or Professional Engineer as necessary until the sewage disposal system and/or private water supply has been constructed and
approved.
Signature of Owner/Agent Date
This form contains personal information subject to disclosure under the Freedom of Information Act. Revised 12/1/2014
s
VDH Use Only
Health Department ID#
Due Date
Site and Soil Evaluation Report
(For certification letters and subdivisions)
General Information
Date: 07//5/Zogi /¢/f,,„,,,,,,,r).e County Health Department
Applicant: Apdpen I s►Jlt✓
Telephone Number: 4/3 y-29G- 9'!j 9
Address: 520 `t ....ire ), .rrice. 5e4c4e /i6 C i/i lerSvr f/e. ✓p zz7,/
Owner: '!�G��h �s�jer Address: see, �✓a,,J.Q j..ra. • X4. /pc
Location : of g e 714-; West g,it 7/y
Subdivision Block/Section Lot
Soil Information Summary
1. Position in landscape satisfactory Yes" No Describe: .,e ,
S/er
2. Slope /y
3. Depth to rock/impervious strata Max. GQ Min. 45 None at
4. Free water present No✓ Yes_ Range in inches
5. Depth to seasonal water table(gray mottlingngor gray color) ALMA inches
6. Soil percolation rate estimated Yes ✓ Texture group ❑I ❑Ii Eti< fly
No_ Estimated rate 65 min/in
7. Percolation test performed Yes Number of percolation test holes_
No ✓Depth of percolation test holes
--�� Average percolation rate mpi
Name and title of evaluator: /1.5o. k. k1j r C.O.O.
Signature: 9:
De tment Use
✓bite approved: Drainfiel rench bottoms to placed at (inches)depth at site designated on permit.
Site disapproved:
Reasons for rejection: (check all that apply)
I. _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)
OSE Form G(pg 1)Revised 7/02/2009
Page 1 of 8
Date of Evaluation: 06/0'7 ii.I` Profile Description
j SOIL EVALUATION REPORT
Property ID: /4%naf, rive.
ive.
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 side or page attached to this form.
Hole# Horizon Depth Description of color,texture,etc. Texture
(Inches) Group
A 0-1, , Ioltgs Ycllo.a L yAF CL./
1st 6- 32 Z.s`Yr 1/L 41 P147 dh47 1.4au-
BG 3z-N9 W/b Ile,.,txl.it.J j ,i+S,lly C447 ions....
R 49"tIfea-
I o Yll '/q ire..,"rs1. Ya X e.., Lc tit t Clasi log,,, 7%
maiprt
$� L9-NS 7.5)x s/9
l�
ccs"+- 5.14:54. ,
3 fl -`I I oYg y/y Agri v-
31- V- Y2 2.sYa '14 R� s a� �� / rc
Br_ _ Y2-1,o . srn rA Y�!/B.,tsl. g4 L-l'3
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REMARKS REMARKS
OSE Form G(pg.2)Revised7/02/2009
Page S of r
Design Calculations
Property ID: �,Z..,e AT /Z1 ,9,�./ 9
Flow
Type of USe(residential, etc) h46i„j„.14-0.1 Show Calculations Here'
No. of bedrooms: 3 Bt
No. of employees: N/JW
Square Footage of building space:Owl&
Daily flow (peak design) in GPD: 'I5
Treatment
No. of septic tanks: t Show Calculations Here'
Size of septic tank(s): l6op lo,,,
Pretreatment required? _yes✓no
If yes, specify type of treatment device:
Absorption area design
Soil Texture Group: ICIf pump system, enhanced flow, or LPD show
Reserve area}equired? s_no calculations here or on a separate sheet.
50% 100%_other(check one) (dosing volume, head, pump design, etc.)
Specify other
Water Supply
Class of well: 0.0 1,./011 Describe (bored, drilled):11rc Prrikj or 4
Distance between septic tank(s) and
well: 50 1-
Distance between absorption area and
oo1-' well: /00'1-
'
Information and calculations required for commercial and/or conditional use applications only
OSE Form I Revised 7/2/2009
Page. (v 0f
Abbreviated Design Form
This form is for use with gravity,pump to gravity,enhanced flow,and low pressure distribution(LPD)sewage
system designs and when applying for a certification letter or subdivision approval.
This abbreviated design covers the lierCimary and reserve area, ❑ only the primary area, 0 only the
reserve area(check one) for 7, Inrij rof ej 9 (property ID).
Design Basis
Total length of available area: 95" Total width of available area: V
Estimated Perc. Rate: SOD at Z tf in.(depth) Number of bedrooms(or GPD): 38g, 9s ' 6PP
Conveyance Method: Distribution method2(specify): AristeLJra•r'h
Dispersal system basis is i5",gel SHIN? LGMI required? /(/a (Yee-CD)
Effluent quality required: Pf;,,,".a,7 CPrimary,Secondary,Advanced Secondary)
Square feet per bedroom: /$Z 4.he Total trench bottom area required: /35 f.4.
Gravity,pump,siphon
z
Enhanced flow,LPD,or Drip Dispersal
Table 5.4 of SHDR or identify the GMP used
Area Calculations
Number of trenches S (Note if a pad is used) Length of pad or trenches: 95
Width of pad or trenches: 3� Center to center spacing: ?
Reserve required? Ie 5 Percent reserve area required: /ad 2
i
Total width of absorption area required 39 Total trench bottom area provided: /YZSs .4.
The required width is calculated by multiplying the center-to-center spacing by one less than the number of
trenches and adding 1 trench width plus any required reserve area. If the topography is not uniform across the
length of the site the trenches will need to flare apart on one end to maintain contour. When this occurs it is
necessary to use a center-to-center spacing that accounts for the flair or the installer will not be able to fit the
system within the approved area. It is perfectly acceptable to have more area available,especially up and down
the slope,than is required.
OSE Form E Revised 7/2/09
Page 1 of S
System Specifications
Property ID: "Al /nor 121sw1 9
Applicant Information
Name //'►;tAe it S,.1 L- Phone y3y-2 9G-71/9
Address SZo .,,,�reL T T ►a,
Gke,(loisille UKI ZZ/e/
Location Information
Tax Map No. /2.1 pi.e4d.1 9 Property address
GPIN No.
Directions ALvflode. 7/S Subdivision
+1- SIS' W.51- al- t,1-e, 7/y Section Block
Lot
General Information
System Type 1r Number of bedrooms 33A
(e.g. septic tank, dra'nfield) Daily flow 415"06PP(gpd)
Type of property Ke 14.44')
(e.g. commercial, residential, etc.)
Conditions
Sewer Line Septic Tank—Inlet/Outlet Structure
Schedule 40 PVC,4" ,-""-or equivalent Capacity: 1000 gallons
(add check or describe equivalent below) 2" septic tank /coo gallons
Per the 2000 Sewage Handling&Disposal
Regulations, Check which option chosen:
Septic tank with inspection port ✓
Septic tank with effluent filter _
Reduced maintenance septic tank
Conveyance line/force main Information Distribution box Information
Method w No. of boxes 1
(e.g. gravity,pum ing, dosing siphon) No. of outlets 12.
If pumping, attach Pump Spec Sheet Surge or splitter box required:
Material 51-1,01,.,1e, y0 PIIL Yes_No ✓
Pipe diameter q"
Slope of pipe(,"-lao (in inches)
Header line Information Percolation line Information/Absorption
Area
1500 pound crush strength Yes ✓ Center to center spacing 1 ft.
Minimum slope is 2"/100 ft. Yes L./ Required spacing 7 ft.
Installation depth 21 inches
Aggregate depth 13 inches
No. of Laterals 5 Lateral length ?S ft.
Lateral bottom slope2'Yinches
Lateral width 34 inches
OSE Date D7//5-/it,/4
OSE Form J Revised 7/2/200
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Fv71
OSE/PE Report for:
Construction Permit ri Certification Letter Subdivision Approval
Property Location:
911 Address: City:
Lot Section Subdivision
GPIN or Tax Map# /21 Health Dept ID#
Latitude Longitude
Applicant or Client Mailing Address:
Name: //t:� e 1 5A.A f e t
Street:
5-ZD 61.as.n,it 1,1 leKAce- Suil-c too
City: G v44,J4e di State 0/ Zip Code 2294
Prepared by:
OSE Name tvphhA £:( Ccens�..l147 LLL Y34/-2-tri-Ot?l License# /7 oa/35'7
Address T.o. `Bid)( 758
City tesla c,k State Of Zip Code ZZ?Y/
PE Name: License#
Address
City State Zip Code
Date of Report 01 IhiZOIC _ Date of Revision#1
OSE/PE Job# Date of Revision#2
Contents/Index of this report(e.g.,Site Evaluation Summary,Soil Profile Descriptions,Site Sketch,Abbreviated Design,etc.)
• '. . . P'7` r
/; ►,,,..+...��y ; :is
• f- Y �< '
Certification Statement
I hereby certify that the evaluations and/or designs contained herein were conducted in accordance with the Sewage Handling and
Disposal Regulations(12 VAC5-610),the Private Well Regulations(12 VAC5-630)and all other applicable laws,regulations and
policies implemented by the Virginia Department of Health. I further certify that I currently possess any professional license required
by the laws and regulations of the Commonwealth that have been duly issued by the applicable agency charged with licensure to
perform the work contained herein.
The work attached to this cover page has been conducted under an exemption to the practice of engineering,specifically the
exemption in Code of Virginia Section 54.1-402.A.11
I recommend that a(spae): construction permits certification letters subdivision approval
be(select one) issued denied❑.
OSE/PE Signature ��, A Date 07//S/2d/G
Pr 2 4$
Commonwealth of Virginia VDH Use only
Health Department ID#
Application for: Sewage System ater Supply Due Date
Owner f ko}►Cr9( St die,' 1 Phone Y31-296-9//7
Mailing Address J`ZO Gee..•wffe/1 rreyocs ,` S,.; /bo Phone
,�1eitr+/10 I/i ie- Up 2276/ Fax
/i/
Agent r'GLes4fcil4 Phone L13�(-296-9j/q
Mailing Address 5-20 ..&,,'e/d /leri,4c•/' £,,�; /pa Phone
G11p.,flp4-Csvil(t VS 2Z94.1 Fax
Site Address
Email
Directions to Property: 4,45,- di, /21,uk. 71SS r 4/' S'/3'+ W
L e•i. d /a,1 1 7/5/
Subdivision Section Block Lot
Tax Map /2 i polec..J ?COther Property Identification Dimension/Acreage of Property 3.19r Acv
Sewage System
Type of Approval:Applicants for new construction are advised to apply for a certification letter to determine if land is -.--
suitable for a sewage system and to apply for a construction permit(valid for 18 months)only when ready to build.
OCertification Letter O Construction Permit O Voluntary Upgrade O Repair Permit-
Proposed
ermitProposed Use:
Single Family Home(Number of Bedrooms 3 ) Multi-Family Dwelling(Total Number of Bedrooms )
Other(describe)
Basement? s-ONo Walk-out Basement DNo Fixtures in Basements - Io
Conditional permit desired?OYes D If yes,which conditions do you want?
❑Reduced water flow ❑Limited Occupancy ❑Intermittent or seasonal use 0 Temporary use not to exceed 1 year
Do you wish to apply for a betterment loan eligibility letter:DYes *There is a$50 fee for determination of eligibility.
Water Supply
Will the water supply befPublic or 'vate? Is the water supplyOExisting o roposed?
If proposed,is this a replacement well?OYes If yes,will the old well be abandoned?OYes ONo
Will any buildings within 50'of the proposed well be termite treated?OYesO
All Applicants
Is this a private sector OSE/PE application? _ es ONo If yes,is the OSE/PE package attached? es ONo
Is this property indeed to serve as your(owners)principal place of residence?DYes Leo
In order for VDH to process your application for a sewage system you must attached a plat of the property and a site sketch. For water
supplies,a plat of the property is recommended and a site sketch is required. The site sketch should show your property lines,actual and/or
proposed buildings and the desired location of your well and/or sewage system. When the site evaluation is conducted the property lines,
building location and the proposed well and sewage sites must be clearly marked and the property sufficiently visible to see the topography.
I give permission to the Virginia Department of Health to enter onto the property described during normal business hours for the purpose of
processing this application and to perform quality assurance checks of evaluations and designs certified by a private sector Onsite Soil
Edaluator or Professional Engineer as necessary until the sewage disposal system and/or private water supply has been constructed and
approved.
Signature of Owner/Agent Date
This form contains personal information subject to disclosure under the Freedom of Information Act. Revised 12/1/2014
0
3o
Fir
VW!Use Only
Health Department ID#
Due Date
Site and Soil Evaluation Report
(For certification letters and subdivisions)
General Information
Date:D7/10/24I6 4/6»yr4c County Health Department
Applicant: A1'4.4 1 54d/er
Telephone Number: '/31—
Address : Sip 6,r+.`„S€(d c iv-i ce. ; 5c4e, /oa GA,,,./ s,,,JJe VA 2294ot
Owner: fl h jt 4R 1 ff flee Address:525 4,,•dt, J4 JJ %.a,,44e.• .51,i f
Li Location : /14,(1-146,1n1 j 4 G 7/5' 4I" 51.S' wesI of A,u4e 7/
Subdivision Block/Section Lot
Soil Inform tion Summary
1. Position in landscape satisfactory Yes No_ Describe: Nose
2. Slope g %
3. Depth to rock/impervious strata Max. 60 Min. 37 None
4. Free water present No • Yes Range in inches
5. Depth to seasonal water table(gray mottling or gray color) A//4 inches
6. Soil percolation rate estimated Yes Texture group Ei Dui II f IV
No Estimated rate 45 min/in
7. Percolation test performed Yes Number of percolation test holes_
No ✓ Depth of percolation test holes
Average percolation rate mpi
Name and title of evaluator: ) 3l o,. K. kySer
Signature: A
Departure se
v4-approved: Drainfield trent ottoms to be pl at i$ (inches)depth at site designated on permit.
_ Site disapproved:
Reasons for rejection: (check all at apply)
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)
OSE Form G(pg.l)Revised 7/02/2009
Page `i of /
Date of Evaluation: O /b7/Z6 1 , Profile Description
SOIL EVALUATION REPORT
Property ID:robe jar I LI rye.' 9C
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 side or page attached to this form.
Hole# Horizon Depth Description of color,texture,etc. Texture
A
(Inches) y/ �/ ) �oa. Group
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B� Y_37 g R'% X�.II,,.,j�1. LI s,t jr clay :.ay., yt
3t 5) * 374 1411b,,451, ,B j 1. Ai-_SS C 1„)w, alek 5-71'4- Rsa.k- hr �"y
REMARKS
OSE Form G(pg.2)Revised7/02/2009
Page 5 Of
Abbreviated Design Form
This form is for use with gravity,pump to gravity,enhanced flow,and low pressure distribution(LPDI sewage
system designs and when applying for a certificationti� letter or subdivision approval.
This abbreviated design covers the primary and reserve area, ❑ only the primary area, ❑ only the
reserve area(check one) for �pX Ar„ /2, .„.ca/ 9� (property ID).
Design Basis
Total length of available area: /5 Total width of available area: /ZO
Estimated Perc. Rate: 45- at /g in.(depth) Number of bedrooms(or GPD): 3&(or 95-0 667)
l 2
Conveyance Method : Distribution method (specify): Grila„e./3
�✓e. I
Dispersal system basis ;th S.V ot 51/DA LGMI required? No (Y= •)
Effluent quality required: ?f;w,,ry (Primary, Secondary,Advanced Secondary)
Square feet per bedroom: 4'96 S',AA, Total trench bottom area required: /Vey . 4.
Gravity,pump,siphon
z
Enhanced flow,LPD,or Drip Dispersal
Table 5.4 of SHDR or identify the GMP used
Area Calculations
Number of trenches 7 (Note if a pad is used) Length of pad or trenches: 75
Width of pad or trenches: 3, Center to center spacing: /
Reserve required? Yes Percent reserve area required: /00/v
Total width of absorption area required 5 7 Total trench bottom area provided: /5-7S'�.4.
The required width is calculated by multiplying the center-to-center spacing by one less than the number of
trenches and adding 1 trench width plus any required reserve area. If the topography is not uniform across the
length of the site the trenches will need to flare apart on one end to maintain contour. When this occurs it is
necessary to use a center-to-center spacing that accounts for the flair or the installer will not be able to fit the
system within the approved area. It is perfectly acceptable to have more area available,especially up and down
the slope,than is required.
OSE Form E Revised 7/2/09
Page ( of S
Design Calculations
Property ID: T Air /2l ps.u/ 1C
Flow
Type of use (residential, etc) Res;1aa:1.1 Show Calculations Here1
No. of bedrooms: 3 sit.
No. of employees: R!/$
Square Footage of building space:ffti14.
Daily flow (peak design) in GPD: (So
Treatment
No. of septic tanks: I Show Calculations Here'
Size of septic tank(s): /off 11.E1
Pretreatment required? _yes
If yes, specify type of treatment device:
Absorption area design
Soil Texture Group: If pump system, enhanced flow, or LPD show
Reserve area required? ✓yes_no calculations here or on a separate sheet.
_ 50% ,/100%_other(check one) (dosing volume, head, pump design, etc.)
Specify other
Water Supply
Class of well: 'G Describe (bored, drilled): Ore A / . &1.J
Distance between septic tank(s) and
well: 5701-1-
Distance between absorption area and
well: /oo'f
Information and calculations required for commercial and/or conditional use applications only
OSE Form I Revised 7/2/2009
Page 1 of g
System S ecifications
Property ID: 714.% M /21 p„../ 9G
Applicant Information
Name in;c fit,,j S4 Air,r Phone (f.31/-294- 7119
Address f2z2 G,r.€.4-4 in loo
Gji,d(bl.ys /I. (hi 22/e/
Location Information
Tax Map No. /21 ~� 4 90 Property address
GPIN No.
Directions AJai+l,,5,d4, of �Q,�,,4c 71c Subdivision
4/' SY (tic 24 o/ 714 Section Block
Lot
General Information _
System Type S Number of bedrooms 3BR_
(e.g. septic tank, drainfield) Daily flow 9S'o (gpd)
Type of property Res.-LW-411
(e.g. commercial,residential,etc.)
Conditions
Sewer Line Septic Tank-Inlet/Outlet Structure
Schedule 40 PVC, 4" ✓ or equivalent Capacity: Mod gallons
(add check or describe equivalent below) 2" septic tank N/p gallons
Per the 2000 Sewage Handling&Disposal
Regulations, Check which option chosen:
Septic tank with inspection port ti
Septic tank with effluent filter _
Reduced maintenance septic tank
Conveyance line/force main Information Distribution box Information
Method 4„,,,.o; No. of boxes /
(e.g. gravity,pumps g, dosing siphon) No. of outlets /2
If pumping, attach Pump Spec Sheet Surge or splitter box required:
Material , f 1.4 J ),c `/o PVC- Yes_No_✓
Pipe diameter 'f
Slope of pipes"-/vo' (in inches)
Header line Information Percolation line Information/Absorption
Area
1500 pound crush strength Yes Center to center spacing ft.
Minimum slope is 2"/100 ft. Yes Required spacing ft.
Installation depth I8 inches
Aggregate depth 11 inches
No. of Laterals 7 Lateral length 75 ft.
Lateral bottom slope34inches
Lateral width 36 inches
OSE 1 Date 07/is*/ye JG
OSE Form 7 Revised 7/2/2009
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i; , Page ( of g.
OSE/PE Report for:
Construction Permit Ti Certification Letter n Subdivision Approval
Property Location:
911 Address: City:
Lot Section Subdivision
GPIN or Tax Map# /2 ribreei 9G Health Dept ID#
Latitude Longitude
Applicant or Client Mailing Address:
Name: /11.-ejteAl $a'.Ale/
Street: 51-20 61'.es,Rlse1ll Iell'Aeloo
City: C,h' (J I+eavi 11 a State Vg Zip Code 22?o/
Prepared by:
OSE Name ;Vp„��„p 1';I CavilLa.Ikk% LLL 0l3`/-ZY9-ot411 License# /7Ydool35-7
Address r,O. ?1/49x 751
City k€S � State 04 Zip Code LZ7f7
PE Name: License#
Address
City State Zip Code
Date of Report 01 11 iZOic Date of Revision#1
OSE/PE Job# Date of Revision#2
Contents/Index of this report(e.g.,Site Evaluation Summary,Soil Profile Descriptions,Site Sketch,Abbreviated Design,etc.)
P ,e /-Z 051E .+.� r JpPlt.ulryyti Qr�c fifty`
fie 3-11 Sale Si. P4-0-7 ; .‘11
fit
Q l o
Certification Statement
I hereby certify that the evaluations and/or designs contained herein were conducted in accordance with the Sewage Handling and
Disposal Regulations(12 VAC5-610),the Private Well Regulations(12 VAC5-630)and all other applicable laws,regulations and
policies implemented by the Virginia Department of Health. I further certify that I currently possess any professional license required
by the laws and regulations of the Commonwealth that have been duly issued by the applicable agency charged with licensure to
perform the work contained herein.
The work attached to this cover page has been conducted under an exemption to the practice of engineering,specifically the
exemption in Code of Virginia Section 54.1-402.A.11
I recommend that a(select ): construction permits certification letters subdivision approval
be(select one) issued denied❑. —
OSE/PE Signature �� , Date Q7//S/Za I .
sk
rr2 °I.S
Commonwealth of Virginia VDH Use only
Health Department I #Application for: r3Seage Systemater Supply
Due Date
Owner Mi c h ei I So dL- Phone 73q-294-V/7
Mailing Address rr J�7.0 e.wf fe/1 ,rrpocs f` Si4de, /b0 Phone
C itwdo 110 L4 227o/ Fax
Agent /f?r'ch cK Iaycil4 Phone 1131-Z? -911
MailingAddress �I -� p
SZD �e��.�"��ld le -�� �r.E:�C /fja Phone
CA f 10 esv;11,e 141 219,01 Fax
Site Address
Email
Directions to Property: /fjAi l k 9 i ii RsuI.c I ii � #/- SI f' f t/c 4 al I yt.J a 7/5/
Subdivision Section Block Lot
Tax Map lZ 1 poi,,,/ 9C Other Property Identification Dimension/Acreage of Property 3.19r*
Sewage System
Type of Approval:Applicants for new construction are advised to apply for a certification letter to determine if land is
suitable for a sewage system and to apply for a construction permit(valid for 18 months)only when ready to build.
®Certification Letter O Construction Permit 0 Voluntary Upgrade 0 Repair Permit-
Proposed Use:
Single Family Home(Number of Bedrooms 3 ) Multi-Family Dwelling(Total Number of Bedrooms )
Other(describe)
Basement? esONo Walk-out Basement13743No Fixtures in Basement( ONo
Conditional permit desired?DYes' If yes,which conditions do you want?
['Reduced water flow 0Limited Occupancy 0Intermittent or seasonal use 0 Temporary use not to exceed 1 year
Do you wish to apply for a betterment loan eligibility letter`aYes( *There is a$50 fee for determination of eligibility.
Water Supply
Will the water supply befPublic or __ ivate? Is the water su 1
pp yDExisting o ... roposed.
If proposed,is this a replacement well?E3Yeso
1.31
If yes,will the old well be abandoned?DYes ONo
Will any buildings within 50'of the proposed well be termite treated?DYes DKr
All Applicants
Is this a private sector OSE/PE application? es ONo If yes,is the OSE/PE package attached?12<ONo
Is this property indeed to serve as your(owners)principal place of residence?DYes[i.
In order for VDH to process your application for a sewage system you must attached a plat of the property and a site sketch. For water
supplies,a plat of the property is recommended and a site sketch is required. The site sketch should show your property lines,actual and/or
proposed buildings and the desired location of your well and/or sewage system. When the site evaluation is conducted the property lines,
building location and the proposed well and sewage sites must be clearly marked and the property sufficiently visible to see the topography.
I give permission to the Virginia Department of Health to enter onto the property described during normal business hours for the purpose of
processing this application and to perform quality assurance checks of evaluations and designs certified by a private sector Onsite Soil
Edaluator or Professional Engineer as necessary until the sewage disposal system and/or private water supply has been constructed and
approved.
Signature of Owner/Agent Date
This form contains personal information subject to disclosure under the Freedom of Information Act. Revised 12/1/2014
a
p,�qc 3 a4
VDH Use Only
Health Department ID#
Due Date
Site and Soil Evaluation Report
(For certification letters and subdivisions)
General Information
Date: A/(tyvv,trl.c County Health Department
Applicant: '!i 4.x41 J�isl J4v
Telephone Number: 4/3y-296-9//9
Address : 5-2e> 6yr114.n 'T nernt. Suik. APO G404,/4sv,JJG VA 22%/
Owner: "ha $4JAddress:526 6644.44M "LreAge, Sade. /go
Location : Nthe+n5,�,c oL 1 7/c; !/' cis ' k'i,I/ (ou4e 7/Y
Subdivision Block/Section Lot
Soil Inform tion Summary
1. Position in landscape satisfactory Yes No Describe :
— Noss
2. Slope g %
3. Depth to rock/impervious strata Max. 60 Min. 37 None
4. Free water present No ✓Yes Range in inches
5. Depth to seasonal water table(gray mottling or gray color) A/�4 inches
6. Soil percolation rate estimated Yes_Texture group El nlI II DIV
No— Estimated rate 45 min/in
7. Percolation test performed Yes Number of percolation test holes_
No ✓ Depth of percolation test holes
Average percolation rate mpi
Name and title of evaluator: Tit}s,. K. k'1.51-
Signature:
Departme�r/ se
mite approved: Drainfield trenc :ottoms to be pl Tat l$ (inches)depth at site designated on permit.
_ Site disapproved:
Reasons for rejection: (check all at apply)
I. —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)
OSE Form G(pg.l)Revised 7/02/2009
Page 9 of
Date of Evaluation: 06/b7/Z4)tj Profile Description
SOIL EVALUATION REPORT
Property ID: pitite_e19C
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 side or page attached to this form.
Hole# Horizon Depth Description of color,texture,etc. Texture
I /� (Inches) V� / 1�I T}TGroup
D -S l0•71v s/ Ye If/l A im.,r. Lr 111-C! I
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1 4 0-G )o ra s/y Y.lle,risl, $,,,,,,,t1, h+£?w 4.,,, T
$+ 4-37 7,sties/G 51.-... 7...w,, Cl f kit.; is
A 37,,..4. /Qock - x)1,r,..4-/ `�
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"t Re6k- 5.t„ -
REMARKS
OSE Form G(pg.2)Revised7/02/2009
Page 5 Of 5
Abbreviated Design Form
This form is for use with gravity,pump to gravity,enhanced flow,and low pressure distribution(LPDI sewage
system designs and when applying for a certificationtiletter or subdivision approval.
This abbreviated design covers the primary and reserve area, ❑ only the primary area, ❑ only the
l
reserve area(check one) for -774,e l /21 1.4,,z./ 34 (property ID).
Design Basis
Total length of available area: 7s'` Total width of available area: /ZO
Estimated Perc. Rate: 45 at /g' in. (depth) Number of bedrooms(or GPD): 3M'er y.S'D l: FD
Conveyance Method:-- r1 z
Distribution method (specify): 4rwu./ 1.7e..,ah
3
Dispersal system basis ��l€ $V pI SF/DQ LGMI required? /vp (Y:40)
Effluent quality required: Pf;w,i (Primary, Secondary,Advanced Secondary)
Square feet per bedroom: 4i 5,Ahe Total trench bottom area required: /y8'8
z Gravity,pump,siphon
Enhanced flow,LPD,or Drip Dispersal
3
Table 5.4 of SHDR or identify the GMP used
Area Calculations
Number of trenches 7 (Note if a pad is used) Length of pad or trenches: 7s
Width of pad or trenches: 3� Center to center spacing: 9
Reserve required? Yts Percent reserve area required: /pp/o
Total width of absorption area required 5 7 Total trench bottom area provided: /s"7
The required width is calculated by multiplying the center-to-center spacing by one less than the number of
trenches and adding 1 trench width plus any required reserve area. If the topography is not uniform across the
length of the site the trenches will need to flare apart on one end to maintain contour. When this occurs it is
necessary to use a center-to-center spacing that accounts for the flair or the installer will not be able to fit the
system within the approved area. It is perfectly acceptable to have more area available, especially up and down
the slope,than is required.
OSE Form E Revised 7/2/09
Page ( of 5
Design Calculations
Property ID: '1,,9, A-hr /2/ /4v.4J?c
Flow
Type of use(residential, etc) Res:lp,„„lird Show Calculations Here'
No. of bedrooms: 3 Bg
No. of employees: A//Jq
Square Footage of building space:/*01 fa..
Daily flow (peak design) in GPD: yca
Treatment
No. of septic tanks: I Show Calculations Here'
Size of septic tank(s): 41202_44m4
Pretreatment required? _yes
If yes, specify type of treatment device:
Absorption area design
Soil Texture Group: If pump system, enhanced flow, or LPD show
Reserve arearequired? ✓yes no calculations here or on a separate sheet.
_ 50% ,/100%_other(check one) (dosing volume, head, pump design, etc.)
Specify other
Water Supply
Class of well: jV Describe (bored, drilled): Pre po•/.I�. Lt. d
Distance between septic tank(s) and
well: rat -
Distance between absorption area and
well: /oo't
Information and calculations required for commercial and/or conditional use applications only
OSE Form(Revised 7/2/2009
Page_1 of g
System S ecifications
Property ID: ax AT/2/ ergo/ `IG
Applicant Information
Name A c heep/ 54Lhe Phone '(3 q-294- ?,/9
Address,5-20 .ld /00
!%{,,r+.iibHKsu/Je. (M 221e/
Location Information
Tax Map No. /21 P,,,„,„J 90 Property address
GPIN No.
Directions IV4,,flAs,d4. of /Q,u,4e 7/5" Subdivision
41- $7s' I ije 54 et 1f L 7,11 Section Block
Lot
General Information
System Type I Number of bedrooms 3M-
(e.g. septic tank, drainfield) Daily flow gro 64p (gpd)
Type of property Resp d. -i
(e.g. commercial, residential, etc.)
Conditions
Sewer Line Septic Tank-Inlet/Outlet Structure
Schedule 40 PVC,4" ✓ or equivalent Cadpacity: /pod gallons
(add check or describe equivalent below) 2° septic tank #//p gallons
Per the 2000 Sewage Handling&Disposal
Regulations, Check which option chosen:
Septic tank with inspection port v
Septic tank with effluent filter _
Reduced maintenance septic tank
Conveyance line/force main Information Distribution box Information
Method fp/ irow,-.1.y No. of boxes /
(e.g. gravity,pumps g, dosing siphon) No. of outlets /2.
If pumping, attach Pump Spec Sheet Surge or splitter box required:
Material J.� L Ye PVC YesNo
Pipe diameter Y" —Slope of pipet"-kw' (in inches)
Header line Information Percolation line Information/Absorption
Area
1500 pound crush strength Yes"— Center to center spacing/ft.
Minimum slope is 2"/100 ft. Yes Required spacing ci ft.
Installation depth 18' inches
Aggregate depth /I inches
No. of Laterals 7 Lateral length 75"ft.
Lateral bottom slope3-4 inches
Lateral width 36 inches
OSE ,> Date o7//S'/Zo/.
OSE Form 7 Revised 7/2/2009
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