013185673 W&S - Laserfiche WebLink

JN. -Date: _ �1S Fee Paid:Ac -7 Accepted - == -Request No/" LCTM No. f/3�7a Planimetric Map No. e Z _.O6D0U1N-COU!1TY HEALTH DEPARTMENT - ENVIRONMENTAL HEALTH SECTION REQUEST FOR INSPECTION OF INDIVIDUAL.SEWAGE DISPOSAL SYSTEM AND WATER SUPPLY SYSTEM (REAL'ESTA%E TRANSFER) Directions from Leesburg to property: Telephone No. (H) oC3 (w) Address: �� _ 0-- Inspection Requested by: Name O�c,'�i✓D IV-_ i�1 ,vitiic Telephone No. Address:_ 5> ?/ -ice Agent: The following must be answered by the owner of the property and signed below in the space provided: 1. Any known history of malfunction or back up of system? ti^ 2. Has septic tank been pumped out in last five years ?� 3. Does all waste water including laundry and sink wastes) from the house go into the septic tank? 4. Has the well ever gone dry? 5. Has the dwelling been continuously occupied for at least 30 days prior to inspec- tion? NOTE: Sewage system performance assessment is significantly more conclusive after 30 days continuous occupancy with the system receiving a normal waste load Reapplication is necessary if re- evaluation is desired. I certify, to the best of my knowledge and belief, that the above information is correct 7 7 DAT T� E OWNER'S SIGNATURE) (This section to be completed by LCHD) INDIVIDUAL WATER SYSTEM (exclusive of house distribution system) 1. Type of Supply: 0 Drilled well: Depth ft.; Cased ft.; Grouted ft.; ❑(Estimated yield in g ions per minute �- Other: Source of Information: 2. Distance from sources of contamination: Septic tank ~70'; drainfield 1 %D0 House ys I ; Other ; 3. Well construction appears to meet current standards: ❑ YES Q NO (Type ) Date of initial visit ; Date of follow -up visit(s) 4. Bacteriological sample(s) collected by Health Department? Q YES �j NO Date(s) of collection: (NOTE: All results are attached to this form and are part of this inspection re ort. 5. Public water available? I _ YES x�j N 6. Comments: of u,Are-lx sU '0'14r, SEWAGE DISPOSAL SYSTEM (exclusive of house plumbing) Date of Evaluation: /9 M.vy87 Source(s) of information: ,PercoAalPvrsU,.c 1. Septic tank: Ej YES [] NO; Size Imo gal. 2. Drainfield System Design: No. of lines '7 ; length of lines 8 ; trench bottom area square footage of system // 9 O 3. System designed to serve: No. of bedrooms .3 ; laundry waste? ✓; garbage disposal ? loo_; Number of occupants (age of system 6 � ) 4. Public sewer available? 0 YES Q NO 4A. Is sewage Pumped to drainfield? YES 5. Violations of code necessitating correction observed? Q YES 0 NO ❑ UNKNOWN 5a. If yes, provide explanation, itemizing deficiencies 6. CommentS:Fu TUTF rFFt u�uT pump �r p� ec �r� T�urT M� tT Cu e to T c tr� �,< At the time this inspection was made, the sewage system appeared to be working satis- factorily 0 unsatisfactorily 0 . Changes in the number of occupants and the amount of sewage being put into the system, lack of system maintenance, unusually wet weather, and age are among causes of system failure. The owner of any occupied property is required, by law, to maintai n approved, properly functioning water supply and sewage disposal yste . Sanitaria Date Z!E / p� 703/777 -0234 Page 1 of a _page report LCHD Rev. 10 -83 COUDOUN COUNTY DEPARTMENT OF PUBLIC HEALTH 209 GIBSON STREET, N,W, IEMBURG, VIRGINIA 22075.2143