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L+lk <br /> LOUDOUN DEPARTN'ENT OF PUBLIC HEALTH ENVIRONMENTAL SURVEY <br /> RICHLAND ACRES <br /> DATE: 7 l O QI : 'JRVEY #: LCTM: <br /> OWNER: '^ U P 2!ti VG,Aie.k OCCUPANT: <br /> ADDRESS: 101 L ..k4' oiL f' 1 - ADDRESS: <br /> HTEL # : ( ?0.3 ) Li `. O nT 0D HTEL # : <br /> WKTEL # : ( ) WKTEL # : <br /> SEPTIC SYSTEM <br /> RECORDS ON FILE: Y N DATE INSTALLED: AGE: YRS <br /> TYPE OF SYSTEM: 5 (ft) SQ. FOOTAGE OF SYSTEM : SEPTIC TANK VOL: GAL <br /> RESIDENTIAL: COMMERCIAL: TYPE OF BUSINESS: # OF EMPLOYEES: <br /> PER RECORDS PER OCCUPANT (OWNER) <br /> # OF BEDROOMS OCCUPANTS ( #) <br /> # OF BATH ROOMS _ INDOOR PLUMBING Y N <br /> KITCHEN SINK Y N DATE SEPTIC TANK LAST PUMPED: <br /> WASHING MACHINE Y N Y N HOW OFTEN? <br /> GARBAGE DISPOSAL Y N Y N DO ALL WASTES ENTER THE SEPTIC SYSTEM? Y N <br /> DISHWASHER Y N Y N IF N, DESCRIBE : <br /> PRIOR PROBLEMS W /SEPTIC SYSTEM? Y N IF Y, PLEASE DESCRIBE, INCLUDE DATES & NATURE OF ANY <br /> REPAIRS �� <br /> REPAIR PERMIT(S) ISSUED IN PAST? [PER RECORDS] /1 Y DESCRIBE: <br /> SYSTEM STATUS: APPEARS TO BE SATISFACTORY: Y N REPAIR AREA AVAILABLE? Y N <br /> (IF N, CIRCLE PROBLEM TYPE) <br /> MF- SEASONAL MF- ONGROUND MF- DISCHARGE MF- BACKUP UNKNOWN <br /> OTHER: <br /> SYSTEM DYED : Y N DATE: DATE DYE OBSERVED: <br /> COMMENTS: <br /> r <br />