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Health Department 309EW91 <br />Identification Number <br />Schematic drawing of sewage disposal system and topographic features. PAGE 2 OF 4 <br />Show the lot lines of the building lot and building site, sketch of property showing any topographic features which may impact on the design of the system, all existing and/ <br />or proposed structures including sewage disposal systems and wells within 100 feet of sewage disposal system and reserve area. The schematic drawing of the sewage disposal <br />system shall show sewer lines, pretreatment unit, pump station, conveyance system, and subsurface soil absorption system, reserve area, etc. When a nonpublic drinking water <br />supply is to be located on the same lot show all sources of pollution within 100 feet. <br />❑ The information required above has been drawn on the attached copy of the sketch submitted with the application. <br />Attach additional sheets as necessary to illustrate the design. <br />TQTER SUPPLY NOTES: <br />1. Refer to the attached site plan and planimetric map for the proposed Class IV <br />well location. <br />2. The proposed Class IV well location must be a minimum of 10 feet from any property <br />line. <br />3. The proposed Class IV well location must be a minimum of 10 feet from edge of <br />any utility easement. <br />4. The proposed Class IV well must be located a minimum of 50 feet from any sewer <br />line. <br />5. The well terminous must extend a minimum of 18 inches above the annual flood <br />level. <br />6. The proposed Class IV well must not be located in a swale or area subject to <br />surface water concentration. <br />7. The area around the well shall be graded to divert surface water away from the <br />well. <br />8. If a dry hole is encountered, the well driller must contact the Loudoun County <br />Health Department at 777 -0234 to obtain a second well permit to drill another well. <br />9. All dry holes must be properly abandoned in accordance with the Loudoun County <br />Health Department specifications prior to the approval of this water supply. <br />10. This water source is not for human consumption. <br />