PSSD-1959-0014 - Laserfiche WebLink

1 41b. J r PERMIT TO INSTALL OR REPAIR WATER SUPPLY and /or SEWAGE DISPOSAL SYSTEMS Date Case No. Owner / �C' < % / " 1si Fi1� Address /�j �t-'� Phone (Mailing Address) Occupant "/; , ; z- -------Address-- Phone (Mailing Address) Exact Location _ of Premises — 'fi'j /� ry e -. f �iG--= 1�1j!��"!_ L _� /) iii ✓1// ST (Subdivision — Section — Lot N o.) ( Stree t, Roa ame or Number) OWNER DESIRES T0: [/INSTALL ❑ REPAIR FOR: ❑ Water Supply System ❑ Water Supply System [j eDwelling ❑ Other - ❑ Sewage Disposal System ❑ Sewage Disposal System Actual or Pote tial Bedrooms__._ Actual or Estimated Water [/Septic Tank ❑ Septic Tank Consumption'` ! - Gal, Per Day Automatic Washing Machine Health Department Recommends: Q }�I1��Q VYes ❑ No Garbage Disposal Unit ❑ Yes No. ❑ •Addi- r✓ - - -------- .- - - - - -- tional Wastes:-- - - - - -- DETAILS OF RECOMMENDED SYSTEMS WATER SUPPLY: Location to be approved by Sanitarian. Type: DETAILS OF CONSTRUCTION: Watertight Septic Tank of ❑ Drilled Well ❑ Driven Well ❑ Bored Well ❑ Dug Well ' ❑ Other Cased _— _feet. (Kind of Material Casing to be properly sealed and vented if necessary. Casing to extend at least 6 inches above pump room floor. Grouted__ feet. All surface drainage to flow away from water supply. Well to have a platform of concrete or other impervious material, at least 4 inches thick at casing, extending at least 24 inches in all directions from casing, gently sloped for drainage. SOIL STUDY: Naturally drained, suitable by sight w ❑ No Technical Classification: Rough Classification: ❑ Sandy Fj;Alediunl ❑ Clay ❑ Pipe Clay Percolation Test Required: ❑ Yes &"No Rate Minutes Per Inch Depth of Water Table __— .._ - _ _ feet i Estimated ) Surface Drainage Required: ❑ Yes 9^1 o Area Drainage by Lowering Ground Water Table Required: ❑ Yes [;J�o Inside dimensions: Length---;7— feet. Width_i� feet. Liquid capacity / jZGallons. HOUSE SEWER LINE: Size_ <l Inches. Type of material L_ required 1 - /_- Distance from Water Supply � e3 feet. SUB- SURFACE ABSORPTION FIELD? Distribution Box required. Ditches of equal length required. Number of square feet required. i/�I_c�-- -_Type aggregate required: j/13roken Stone ❑ Gravel ❑ Slag. Size range from 1 /z inch to 2' -z inches Depth of aggregate from base of tile to bottom of ditches - - - inches. Total aggregate must equal minimum depth of 13 inches or more. Soil Cover over tile not to exceed /,c�- inches. Distance from Sewage Disposal yst.em to the nearest point of a Water Supply WjVMMw will be" - feet. Rough Sketch of Premises (including adjacent properties If pertinent, Showing Location of Lot Line, Buildings, Water Supplies, Sewage Disposal Sys- tems, Trees, and Other Possible Sources of Contamination of Water Supplies. by Indicating Distances and Slope with regard to one another. f� l� j, � 1 t � 1 1 + 1 f— JU0 C 1 Note: Owner or his agent must notify em i, ov ere . , d b _- _Health Department, Phone when installation Is ready for inspection. If any Sewage Disposal Syst, or p rt there - b('ls cefore being inspected by the Health Department, it shall be uncovered at the direction of the Health Director or his agent. CONDITIONS DISCOVERED DURING INSTALLATION MAY REQUIRE ADJUSTMENTS OF SYSTEM DESIGN. Changes from above specifications require Health Department approval before being made. Based on the above information, the undersigned re ^ommends that this permit be issued. r% Date Signed ,�. �� (Sanitarian of - Health Director) LNS - 121 Rev. 11 -57 Virginia State Department of Health Date Signed (Reviewing Authority)