Laserfiche WebLink
OSE/PE Report For: <br />Construction <br />Permit <br />Certification <br />Letter <br />Subdivision <br />Approval <br />Property Location: <br />911 Address: _______________________________________________________ City: _________________ <br />Lot _________ Section ________________________ Subdivision___________________________________ <br />GPIN or Tax Map # _______________________________ Health Dept ID # ___________________________ <br />Latitude ________________________________________ Longitude <br />_________________________________ Applicant or Client Mailing Address: <br />Name: ___________________________________________________________________________________ <br />Street: ___________________________________________________________________________________ <br />City: _________________________________________ State _______________Zip Code ________________ <br />Prepared by: <br />OSE Name ______________________________________________ License # ______________________ <br />Address _________________________________________________________________________________ <br />City _________________________________________ State ______________ Zip Code <br />PE Name _______________________________________________License # __________________________ <br />Address __________________________________________________________________________________ <br />City _________________________________________ State ______________ Zip Code _________________ <br />Certification Statement <br />I hereby certify that the evaluations and/or designs contained herein were conducted in accordance with the applicable provisions of <br />the Sewage Handling and Disposal Regulations (12 VAC5-610), the Private Well Regulations (12 VAC5-630), the Regulations for <br />Alternative Onsite Sewage Systems (12VAC5-613) and all other applicable laws, regulations and policies implemented by the Virginia <br />Department of Health. I further certify that I currently possess any professional license required by the laws and regulations of the <br />Commonwealth that have been duly issued by the applicable agency charged with licensure to perform the work contained herein. <br />The potential for both conventional and alternative onsite sewage systems has been discussed with the owner/applicant. <br />The work attached to this cover page has been conducted under an exemption to the practice of engineering, specifically <br />the exemption in Code of Virginia Section 54.1-402.A.11 <br />I recommend that a (select one): construction permit certification letter subdivision approval be (select one) Issued <br /> Denied <br />OSE/PE Signature ________________________________________________ Date ______________________________ <br />Contents/Index of this report (e.g., Site Evaluation Summary, Soil Profile Descriptions, Site Sketch, Abbreviated Design, etc.) <br />________________________________________________ _____________________________________________________ <br />________________________________________________ _____________________________________________________ <br />________________________________________________ _____________________________________________________ <br />________________________________________________ _____________________________________________________ <br />Date of Report _________________________ Date of Revision #1 ____________________ <br />OSE/PE Job # __________________________ Date of Revision #2 ____________________ <br />Repair <br />Permit <br />Voluntary Upgrade <br />Permit <br />repair permit voluntary upgrade <br />This form contains personal information subject to disclosure under the Freedom of Information Act. Revised 9/1/2017 <br />Christopher Froemel <br />Page 1 of 5