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LOUDOUN DEPARTMENT OF PUBLIC HEALTH ENVIRONMENTAL SURVEY <br /> RICHLAND ACRES <br /> DATE: 2 3 D J 0 I SURVEY #: LCTM: g'/- 4- y- 2 Z <br /> ' OWNER:Ai 1.c 44 ck Sp I OCCUPANT: <br /> ADDRESS: t . q, L cti--c OR +0- ADDRESS: <br /> HTEL # : ( 703 ) L j D to 145 HTEL # : ( ) <br /> WKTEL # : ( ) WKTEL # : ( ) <br /> SEPTIC SYSTEM <br /> RECORDS ON FILE: Y N DATE INSTALLED: AGE: YRS <br /> /� <br /> TYPE OF SYSTEM: v SQ. FOOTAGE OF SYSTEM : (?± a SEPTIC TANK VOL: 1- C-- GAL <br /> RESIDENTIAL: y COMMERCIAL: TYPE OF BUSINESS: # OF EMPLOYEES: <br /> PER RECORDS PER OCCUPANT (OWNER) <br /> # OF BEDROOMS OCCUPANTS ( #) <br /> # OF BATH ROOMS INDOOR PLUMBING () N <br /> KITCHEN SINK N DATE SEPTIC TANK LAST PUMPED: IS y JZS <br /> - WASHING MACHINE N Q N HOW OFTEN? <br /> GARBAGE DISPOSAL N ,9 N DO ALL WASTES ENTER THE SEPTIC SYSTEM? Y N <br /> DISHWASHER l 7' N Y N IF N, DESCRIBE : <br /> PRIOR PROBLEMS W /SEPTIC SYSTEM? LY/ N IF Y, PLEASE DESCRIBE, INCLUDE DATES & NATURE OF ANY <br /> REPAIRS / 'aAi i Phi ,,.,e el Co"` ` Dfh O /I <br /> R�CPAIR PERMIT(S) ISSUED IN PAST? [PER RECORDS] N DESCRIBE: 702 �LDrr.4-0 T -p, 1 q 4.---)0 <br /> SYSTEM STATUS: APPEARS TO BE SATISFACTORY: N REPAIR AREA AVAILABLE? r Y N <br /> 1 (IF N, CIRCLE PROBLEM TYPE) <br /> MF- SEASONAL MF- ONGROUND MF- DISCHARGE MF- BACKUP UNKNOWN <br /> OTHER: <br /> • <br /> SYSTEM DYED : Y N DATE: DATE DYE OBSERVED: <br /> t <br /> COMMENTS: <br /> J <br />