Laserfiche WebLink
C At j S 7 Fee Paid: Accepted b <br />er_` �•� p _Request No. �lY. LCTM No <br />Planin tric Map No. <br />_ - <br />--------------------- <br />------------------------------------------------ <br />JOUDOU11 COUNTY HEALTH DEPARTMENT- ENVIRONMENTAL HEALTH SECTION <br />REQUEST FOR INSPECTION OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM <br />AND WATER SUPPLY SYSTEM (REAL ESTATE TRANSFER) <br />.) <br />Owner: R Robe" Telephone No. (H)4.30 -457 (w1��� 3Jo <br />Address • it 3 Luy,.lr,,. t)•. Slcrl i nc, 121-70 <br />Inspection Requested by: Name �., ?� Telephone No. <br />Address: Agent: <br />The following must be answered by the owner of the property and signed below in the <br />space provided: <br />1. Any known history of malfunction or back up of system? o 2. Has septic tank been <br />pumped out in last five years? r5 3. Does all waste water including laundry and sink <br />wastes) from the house go into the septic tank? Nv 4. Has the well ever gone dry? ))o <br />5. Has the dwelling been continuously occupied for at least 30 days prior to inspec- <br />tion ?_L�_, NOTE: Sewage system performance assessment is significantly more conclusive <br />after 30 days continuous occi anc with the system receiving a normal waste load, <br />Reapplication is necessary if re- evaluation is desire . <br />certify, to the best of my knowledge and belief, that the above information is correct. <br />2 3/f) a", Z <br />DATE (OWNER'S SIGNATURE <br />(This iection to be completed by LCHD) <br />INDIVIDUAL WATER SYSTEM (exclusive of house distribution system) <br />1. Type of Supply: rVl Drilled well: Depth ft.; Cased <br />f��ft.; Groutedt/ v<gt.; <br />(Estimated yield in ga lon per minute T- <br />V Other: Source of Information: <br />i.t . 2. Distance from sources of contamination: Septic tank_; drainfi ld moo': <br />House I " ; Other ; <br />3. Well construction appears to meet current standards: S Q NO (Type <br />Date of initial visit�q�;,. -CE ; Date of follow -up isit(s) <br />4. Bacteriological sample(s) collected by Health Department? Q NO <br />Date(s) of collection:'y,„Eb7 <br />(NOTE: All results are attached to this f rm and are art of this ins ection re ort.) <br />5. Public water available? YFe <br />U i` <br />6. Comments: <br />SEWAGE DISPOSAL SYSTEM (exclusive of house plumbing) <br />Date of Evaluation: �,y .S7 Source(s) of information: , u'6 ",l <br />1. Septic tank: [2 YES E] NO; Size ,jQQ4al. <br />2. Drainfield Sytt`em Design: No. of-lines _�; length of lines _�QV <br />trench bottom area square footage of system y ' <br />3. System designed to serve: No. of bedrooms; laundry waste ?Y&-S, garbage <br />disposal? //0 Number of occupants (age of system <br />4. Public sewer available? 0 YES 4A. Is sewage Pumped to drainfield? YES L .A- <br />5. Violations of code necessitating correction observed? YES ( UNKNOWN <br />5a. If yes, provide explanation, itemizing deficiencies <br />6. Comments: i1 /-) /1/1111//,, _.% _ /)L.,. 1 \ _ #. „ _ . - _ <br />At the time th <br />factorily unsatisfactorily 0 . Changes in the number of occupants and the amount <br />of sewage being put into the system, lack of system maintenance, unusually wet <br />weather, and age are among causes of system failure. The owner of any occupied <br />property is required, by law ' to/4mintain an approved, properly functioning water <br />supply and s wa sal ys M. <br />Sanitarian Date <br />10 -0 34 Page ] of a _page report <br />LCHD <br />Rev. 10 -83 COUDOUN COUNTY <br />DEPARTMENT OF PUBLIC HEALTH <br />209 GIBSON STREET, N,W, <br />LEMBURG, VIRGINIA 22075.2193 <br />