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RECORD OF INSPECTION SEWAGE DISPOSAL SYSTEM <br />Date 5 - 12 - 59 Case No. <br />Owner E. C. Br Address Herndon Phone <br />(Mailing Address) <br />Occupant Same <br />Exact Location <br />of Premises <br />(MailimT Address) <br />- Broad Run District <br />Phone <br />(Subdivision, Street or Rdod Name, Section or Lot No.) <br />WATER SUPPLY INSPECTION <br />Installed According to Permit Design- ❑ Yes ❑ No. Distance to Nearest House Sewer feet. Distance to Nearest Sewage <br />Disposal System feet. (Use Form LHS -143 for Detailed Inspection of Water Supply Reference Materials.) <br />(1) LOCATION: <br />Alloted Area Adequate: Yes <br />est: Lot Lines_ feet._. <br />Water Supplie feet. _Built mgs eet. <br />(2) INSTALLATION AND DESIGN: ,� <br />Installed According to Permit Design: � Yes El No <br />Have Additional Household Appliances Been Added NOT on <br />Permit: ❑ Automatic Washer [] Garbage Disposal <br />F71 Other _ <br />(Describe) <br />(3) SOIL CONDITION: <br />Are there soil conditions now evident which in lie to system <br />may be unsatisfactory as designed: El Yes o. If Yes, <br />show adjustments required under "Remarks" below. <br />(4) HOUSE SE LINE: <br />Ile es No. Type of material: <br />� <br />� QIJ� Size Inches. <br />(5) SEPTIC TANK: <br />Constructed of <br />nd lAi Material) <br />Inside Dimenslo Length feet. Width` y_feet. <br />Liquid Depth feet. Depth of Air Space ���ches. <br />Inside Fittings comply with requirements: es ❑ No. <br />extra outlets for future use. <br />(7) SUB - SURFACE ABSORPTION F;ELD: <br />Total Area in Bottom of Ditches 4�4— square feet. <br />Number of Ditches Len h of Ditches �o o feet. <br />Grade of Ditc 1 in 11 111111 Inches per 100 feet. <br />Maximum _ inches per IW) ff t. Has system been <br />checked by instruments ( , 1 F }� , El No <br />Type Aggregate Used <br />Depth of Aggregate Under Tile inches <br />Total Depth of Aggregate — inches <br />Depth of Backfill Over Aggregate yeq inches <br />(3) SURFACE DRAINAGE: <br />Storm Drains from House and Ba,ey t Flowing Away from <br />Sub- Surface Drainage Field: [7'Y ❑ No. Was Surface <br />Drainage Required: ❑ Yes ��IVo. If Yes, has this been <br />provided: L7 Yes F] No. Has area been drained by lower- <br />ing Ground Water Table: E] Yes [] No Woo dot Required. <br />(J) Are follow -up inspections necessary: El Yes [I No. <br />Septic Tank <br />Contractor: C�.0 -- Zg�m Address ��/�G Phone '.7 y <br />This System (Is) E4e.?iot) Approved by ��//� �����! Health Department. <br />With proper maintenance, approved systems may be expected to function satisfactorily, provided no overloading or physical dam- <br />age occurs to the system. Remarks: <br />Date �- <br />Signed <br />Date `7 / / S y <br />/ / <br />Approved <br />Date <br />Approved <br />Date Approved <br />Virginia Department of Health <br />LHS - 141 11 -57 <br />_. A`drace <br />North end of 603 off Seneca <br />r <br />(Health U' orl <br />(Advisory Sanitarian) <br />(Reviewing Authority — Other Agency) <br />® s -12 -51 <br />SEWAGE DISPOSAL SYSTEM INSPECTION <br />(G) DISTRIBUTION BOX: <br />E] No Distance from near- Watertight and equal surcharge to each line by W,�ter Test: <br />Trees eet. � es E] No. Distribution Box provided with <br />U f (Number) <br />