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• <br /> LYNew Installatio �] / -. . / <br /> _ , Repairs ��1� �C� // J Date " � � 7 <br /> PERMIT TO INSTALL OR REPAIR <br /> L/7„:...HJ WATER SUPPLY AND /OR SEWAGE DISPOSAL SYSTEM <br /> Owner le, Address _ c...i.7. /e' / / Phone <br /> (Must be filled (Mailing Address) <br /> Occupant __— _— . /4 Address Phone _. <br /> Contractor ! ' �'+ . -4/4" /'Q -- — Address / / F i Ii yj ( / l j -- - ems) /Q 4 Phone p - .. 7 e 7 f <br /> Location of <br /> (Mailing Address) 1 <br /> Premises _! Ze _ 7,e /��/- Cif/ /3 -0 /r% 5 /,'-' - r /,E"e' � - to?" d <br /> (Subdivision, Street or Road Name or Number, Section, Lot No.) <br /> Directions <br /> Owner <br /> Desires to: t Z1 Install '! Repair [I Water Supply System: Type <br /> ❑ Sewage Disposal System: Septic Tank ❑ Other <br /> Lot Size: Width Ft. Depth -- Ft. <br /> �� <br /> FOR: izr Single Dwelling Unit ❑ Multiple Dwelling Unit Total No. 1 Estimated or Actual <br /> Bed Rooms ,J Water Consumption 7 o Oral. <br /> SEPTIC TANK SYSTEM - Ordinary Household ❑ In Addition Wastes from ❑ Garbage <br /> FOR DISPOSAL OF: Sewage & Wastes Automatic Washing Machine Disposal Device <br /> ❑ Additional <br /> Living Quarters ❑ Other <br /> ( Explain) (Explain) <br /> Health <br /> Department: ❑ Recommends ❑ Rejects: Water Supply System <br /> ?' Recommends ❑ Rejects: Sewage Disposal System <br /> Reasons for Rejection <br /> and Recommended Alternatives: <br /> DETAILS OF RECOMMENDED SEPTIC TANK SYSTEM <br /> Kind of Material <br /> for Tank: Concrete ❑ Other <br /> Size of <br /> Tank: Length N Q Ft. Width j _ Fe 1 .-. Depth Ft. Capacity /e'er, e2 Gallons <br /> Subsurface No. of Exact Length _ of Depth of 1 / j O <br /> Drainage Field: Ditches r./ - of Each Ditch —. Ft. Ditches i _ Ft. Ditches 7 Inches <br /> Depth of Filter Material Depth of 7 / Surface Drainage Linear <br /> From Base to Cover Tile /� Inches Water Table -/Z ' 'r Ft. Required _ Ft. <br /> No. of <br /> Percolation Tests ❑ Holes Results <br /> /I Ee,-, -, �'7 Eine , f11 <br /> Signe. // .._ Date -� <br /> (Sanitation Officer) <br /> Rough Sketch of Premises Showing Location of Buildings, Water Supply System, Sewage Disposal System and other Pertinent Details <br /> I <br /> I ` t <br /> 1 <br /> 1 1 1 <br /> 1 t I I <br /> ., 1 t ; t 1 <br /> ci ■ 1 1 j 1 <br /> T , ' • <br /> I 1 • 1 <br /> if t 1 t I ` <br /> t 1 t ' 1 <br /> r 1 1 1 1 1 <br /> f t i l t <br /> 1 t <br /> 1 , 1 1 ' t I t //j/e�/i <br /> I t <br /> t tttt1 <br /> I t t t <br /> 1 1 1 t t <br /> I t t 1 <br /> N <br /> li L-•' - -.. li _ ✓Lfl.� /E _� Depth. Ft / <br /> Note: This is a Permit to Construct or Repair Subject to Inspection. (Owner or his Agent) must Notify <br /> ✓� OdG rilY <br /> Health Department when Installation is ready for Inspection. If any Septic Tank or Part thereof is covered before being inspected by the <br /> Health Department, it shall be uncovered by the owner at the direction of the Health Officer or his Agent. <br /> LHS 121 -50M Virginia State Department of Health <br />