HomeMy WebLinkAbout06-08 CommentsREQUEST FOR CONDITIONAL USE PERMIT COMMENTS
Virginia Department of Transportation
Attn: Resident Engineer
14031 Old Valley Pike
Edinburg, Virginia 22824
(540) 984-5600
The local office of the Transportation Department is located at 2275 Northwestern Pike in
Winchester if you prefer to hand deliver this form_
Applicant's name, address and phone number:
Name of development and/or description of the request:
Location:
94'? ma'pd60" 24
Va. Dept. of Transportation Comments:
The application for a Conditional Use Permit for this property appears to have little measurable
impact on Route 631, the VDOT facility which would provide access to the property. Prior to
operation of the business adequate sig is ance west ot the existing entrance (500 reer rbr 45
PerfgFmed- A --P the _State% right-of-way to improve sight distance Must hl_r�yp . rprl iindpr a land
use permit. The permit is issued by this office and requires an inspection fee and surety bond
coverage. � \ -
VDOT Signature and Date: ec:41R,,1 �4LE�RETIUPN
�1 '
i(NOTICE TO RESIDENTENGIRT E TINS FbRIA TO APPLICANT.)
NOTICE TO APPLICANT
It is your responsibility to complete this form as accurately as possible in order to assist the agency
with their review. Also, please attach two (2) copies of your application form, location map and all
other pertinent information.
REQUEST FOR CONDITIONAL USE PERMIT COMMENTS
Frederick County Fire Marshal
ATTN: Fire Marshal
1080 Coverstone Drive
Winchester, Virginia 22602
(540) 665-6350
The Frederick County Fire Marshal is located at 1080 Coverstone Drive, at the Public Safety
Building if you prefer to hand deliver this review form.
Applicant's name, address and phone number:
Ne -(en —3&ale y y -Pi e 41r, - i.- 6
q67 /• aalbo,w .Ram, S+e.p1,ernS ca" I, UQ. a1GS!�
Name of development and/or description of the request:
Location:
�•� rr�des t�esf- � ,�- it ..�:r• S-i-e��►ens � �.
�ia 7 ► v `cr.2(�y r�.� �0 4.c�.
Fire Marshal Comments:
Fire Marshal Signature & Date
(NOTICE TO FIRE MARSHAL - PLEASE RETURN THIS FORM TO APPLICANT.)
NOTICE TO APPLICANT
It is your responsibility to complete this form as accurately as possible in order to assist the agency with their
review. Also, please attach a copy of your application form, location map and any other pertinent
information.
-rom:LIFESAFE
05/" 2008 11:21 #085 P.001/001
re
3
Control number Date received Date reviewed Date Revised
%t""-;,€ =;; 4/30/2008 5/6/2008
Project Name Applicant
Barleyfield Farm Cottage Bed 8 Breakfast Helen Barley
Address City State Zip Applicant Phone
967 Marlboro Road Stephens City VA 22655 540-869-1222
Type Application Tax ID Number Fire District Rescue District
Conditional Use 74 -A -13A 71 11
Current Zoning Election District
R Recommendations
Back Creek
Automatic Sprinkler System Automatic Fire Alarm System Residential Sprinkler System
No Yes Yes
Other recommendation
Emergency Vehicle Access Hydrant Location Fire Lane Required
Not identified No
Siamese Location Roadway/Aisleway Width Special Hazards
No
Emergency Vehicle Access Comments
Access Comments
Additional Comments
Plan Approval Recommended {r P
Reviewed By Signature
Yes J. Neal r
Title �, f
Inspector (print)
Inspector (signature)
Received by (print)
Received by (signature)
F"DERICK COUNTY FIRE & RESCUE DEPARTMENT
OFFICE OF THE FIRE MARSHAL,
Following Conditions Need Corrections:
1080 Coverstone Drive
BUILDING
EXIT AND EGRESS
Winchester, Virginia 22602
Unapproved or defective gas connection
1.
(540)665-6350
531.
Date: f,
562.
OF INSPECTION
,112.
Broken ceilings and/or walls -exposed lath on
7TYPE
hen / hood
Second means of egress not readily accessible
inkler / ss
ceilings and/or wall *unnatural openings)
m system
Aisles and/or passageways obstructed
563.
rhead door
Street No.
Street Name Suite/Apt.
building
ing
Panic hardware (anti -panic latches & bolts)
564.
permit
spark arrestor screen
.ting
required on exit doors
ORDINARY HAZARDS
8. C Fumigation
Cardboard ceilings and/or walls
Occupant / Business Name Telephone
9. ❑ Tent
565.
Poor housekeeping conditions
10. ❑ Plan review
Fire door not serviceable
536.
11. ❑ UST installation
566.
Improper storage
12. ❑ UST leak
Fire door blocked or wedged open
Manager/Re resentative Telephone
13. ❑ UST removal
14. ❑ UST liquid
067.
Storage of floor oils, cleaning compounds, etc.
spill
Oil soaked wood floors
C38.
15. C Annual inspection
1-68.
Storage of excelsior, straw, sawdust, burlap, etc
16. C Complaint
17.0 Violation
18. ❑ Fire lane inspection
Building Owner's Last Name Owners Address Tele hone
539.
Exit lights provided by not operative
19. 11 Fire lane approval
Metal drip pans required, but not provided
20. 0 Re -inspection
540.
Illuminating directional signs to exits required
21. 5 Other
Fire Prevention Permit No.
Re -Inspection Date Max Occupancy Load
Door requiring self-closing device not so equipped
Inspector (print)
Inspector (signature)
Received by (print)
Received by (signature)
INSPECTION GUIDELINE - CORRECTIONS REQUIRED
The
Following Conditions Need Corrections:
BUILDING
EXIT AND EGRESS
561.
Unapproved or defective gas connection
1.
Space under stairs used for storage purposes
531.
Inadequate means of egress
562.
Damaged or deteriorated vent pipe on gas burning
,112.
Broken ceilings and/or walls -exposed lath on
❑32.
Second means of egress not readily accessible
appliance
ceilings and/or wall *unnatural openings)
533.
Aisles and/or passageways obstructed
563.
Vent hood, vent and/or duct systems need cleaning
3.
Defective and/or unapproved incinerator and/or
534.
Panic hardware (anti -panic latches & bolts)
564.
Combustibles being stored near hot water heater
spark arrestor screen
required on exit doors
ORDINARY HAZARDS
4.
Cardboard ceilings and/or walls
535.
Discharge from exits, outside building, etc
565.
Poor housekeeping conditions
5.
Fire door not serviceable
536.
Exitway blocked and/or obstructed
566.
Improper storage
6.
Fire door blocked or wedged open
037.
Exit door locked and/or barricaded
067.
Storage of floor oils, cleaning compounds, etc.
7.
Oil soaked wood floors
C38.
Exit not properly designated or marked
1-68.
Storage of excelsior, straw, sawdust, burlap, etc
8.
Attic areas open to the outside. Screen to prevent
539.
Exit lights provided by not operative
569.
Metal drip pans required, but not provided
entry by birds.
540.
Illuminating directional signs to exits required
1-170
Excessive grease on stove
519.
Door requiring self-closing device not so equipped
DAL
Exit door swinging against line of exit travel
571.
Cockloft cover off
l0.
Prohibitive -should be razed
542.
Stairways not properly enclosed and/or equipped
572.
Unapproved trash containers
511.
Open and exposed foundation beneath building
with non-standard doors
SPECIAL
HAZARDS
0112.
Post max occupancy load
E43.
Stairways not properly illuminated
1173.
Unnecessary and/or disorderly accumulation of
ELECTRICAL
544.
Emergency white lights
Boxes, etc. collapse -maintain orderly arrangement
1113.
Illegal and/or boot -leg wiring
FIRE
PROTECTION
774.
Smoking in hazardous location. "No Smoking"
C 14.
Inadequate service and/or insufficient circuits
545.
Fire extinguishers required, but not provided
signs needed
515.
Insufficient receptacles
546.
Fire extinguishers need recharging/inspection
1175.
Flammable liquids/gases improperly used/stored
516.
Defective, deteriorated or spliced wiring
047.
Unapproved type fire extinguishers
076.
Inadequate ventilation in hazardous location
017.
Defective and/or broken fixtures
1148.
Fire extinguishers not properly mounted 4"-60"
577.
Storage of compressed gas cylinders without
518.
Defective and/or broken switches and/or sockets
549.
Fire extinguishers not readily visible
proper anchorage (racks or chains)
519.
Circuit breakers by-passed or blocked open
1-50.
Standpipe hose deteriorated/not racked
L78.
Oxygen cylinder stored/used in greasy/oily location
520.
Oversize fuses and/or circuit breakers set too high
551.
Fire protection system
579.
Oxygen cylinder stored near acetylene/fuel gas cyl
521.
Pennies behind plug type fuses
552.
Defective standpipe nozzle
580.
Oxidizing material stored with acids, sulfur, etc
F,22.
Metal strip of fuse holder cut back
053.
Standpipe system disconnected
[Al.
Unapproved and/or hazardous paint spraying
'123.
Fuses jumped or bridged
1-354.
Sprinkler heads, cut-offs or Siamese blocked
1-82.
Trash room door not equipped w/self-closing device
524.
Open junction box and/or fuse box
555.
Inadequate sprinkler head clearance (18" required)
583.
Open flame heating in hazardous location
1 25.
Fuse panel obstructed and/or inaccessible 30"
556.
Sprinkler valves not properly identified
n84.
Vacant at time of inspection
526.
Motors and/or fans dirty or dust covered
HEATING AND COOKING
585.
Locked at time of inspection
727.
Unapproved extension cords/drop cords
057.
Defective heating unit-fumace, gas boiler, stove, etc
586.
See supplement sheet
1128.
Excessive use of multiple outlet plugs
058.
Defective cooking unit -range, hot plate, etc
1787.
IN THE OPINION OF THE OR
INSPECT,
529.
Lamps, fixtures, equipment, etc. Not properly
x759.
Gas meter blocked and/or obstmcted/not protected
THERE WERE NO HAZARDOUS
enclosed (hazardous locations only)
060.
Furnace, boiler, heating, cooking and/or smokepipe
CONDITIONS IN THIS AREA AT THE
030.
Dead and unused wiring; should be removed
and vent pipe clearances from combustible
TIME OF THIS INSPECTION
materials, not standard
COMMENTS: . ,
Inspector (print)
Inspector (signature)
Received by (print)
Received by (signature)
REQUEST FOR CONDITIONAL USE PERMIT COMMENTS
Frederick County Inspections Department
Attn: Building Official
107 North Kent Street, Suite 200
Winchester, Virginia 22601
(540) 665-5650
The Frederick County Inspections Department is located at 107 North Kent Street, 2nd floor of
the County Administration North Building in Winchester, if you prefer to hand deliver this
review form.
Applicant's name, address and phone number:
%'1 lbo-ed-rw RicA' - "
540- $0_ tz�z
Name of development and/or description of the request:
e �t� n �Ry- % ize A �o .�- a-. •R s t—" j C.v
Location:
ides Wes-- z 0- 11
Inspections Department Comment:
Code Administrator Signature &Date: f\-/ , S-�
(NOTICE TO INSPECTIONS DEPT*PLE RETURN TIM FORM TW-Ai4PL1CdNT Y
NOTICE TO APPLICANT
It is your responsibility to complete this form as accurately as possible in order to assist the
agency with their review. Also, please attach two (2) copies of your application form, location
map and all other pertinent information.
REQUEST FOR CONDITIONAL, USE PERMIT COMMENTS
Winchester -Frederick County Health Department
107 North Kent Street, Suite 201
Winchester, Virginia 22601
(540) 722-3480
The Winchester -Frederick County Health Department is located in the County Administration
Building at 107 North Kent Street in Winchester, if you prefer to hand delivered this form.
Applicant's name, address and phone number:
e le- n "Ie -!i e y %3ctRle L �', c Id �c-qtr,
�r M a-a-f&a.
kens ill
WI-9— I11a-
Name of devel pment and/or description of the request:
S� a IVi2fJ0 rS r?o
CLi i 11 A
Location:
/.%
cl (e?
Health Department Comments:
1 (,O'" C: U' 1 �" w� .. y rJ✓ a4 v S'�v Yi Q i i l' S ' , T2
t- oi! /ALL -C rr. tt
�.� i .i I ,k t tT ,ft �II- zJ c i fihe eA
�1 3br iii i� D
„ /11,I ✓ .
Signature and Dater )Z
dict ht COhJiti,— j 6,k /6-1 �7 fr iyp/ eft i"vI d-llt c Y'c
Ae—f I I 4 9 UV ei1 , I
NOTICE TO APPLICANT 1W
It is your responsibility to complete this form as accurately as possible in order to assist the SILvI�Y
agency with their review. Also, please attach a copy of your application form, location map and
all other pertinent information.
Lord Fairfax Environmental Health District
107 N. Kent St.
Winchester, Virginia 22601
, (540) 722-3480 FAX (540) 722-3479
Counties of: Clarke, Frederick, Page, Shenandoah, Warren, and City of Winchester
Helen Barley May 12, 2008
967 Marlboro Rd.
Stephens City, VA 22655
Subiect: Request for conditional use permit comments.
Mrs. Barley,
The Frederick/Winchester Health Department will require additional information
and clarification on the proposed bed & breakfast. No information was available under
the tax map number listed on your request, however, two older permits dating back to
1957 and 1960 were found under the name Miller Barley. Any records for the septic
system and water supply will aid in your request. A site visit may be necessary to match
the older permits to your property. The older permits for Miller Barley are for a two (2)
bedroom on one property and a one (1) bedroom on the other. If the cottage were to be
added on as a bed & breakfast, the Health Department would need to verify the existing
drain -field on your property could handle the increased water usage or if additional
facilities would need to be added. The Health Department would also need a yearly
water test from an approved water source. Please provide information for the source of
potable water for the proposed bed & breakfast. Also, be aware the Planning and Zone
Department have restrictions on more than one structure being connected to the same
sewage disposal system.
Please elaborate on the number of meals that will be provided to the guest of the
bed & breakfast. The Commonwealth of Virginia Board of Health Food Regulations
state " a bed & breakfast operation that prepares and offers food only to guests if the
home is owner occupied, the number of available guest bedrooms does not exceed six,
breakfast is the only meal offered, the served does not exceed 18, and the consumer is
informed by statements contained in published advertisements, mailed brochures, and
placards posted at the registration area that the food is prepared in a kitchen that is, by
these regulations, exempt from this chapter." Basically, no additional food facility
permit is needed. However, if additional meals are offered or other criteria are not met,
then a food facility permit will be required and the food regulations enforced in addition
to the bed & breakfast permit.
Lastly, please list any additional uses of the bed & breakfast or kitchen facility
like temporary events, festivals... that may require further thought and planning by the
Health Department.
If there are any questions, please call at 540-722-3480 or email at
matthew.cloud@vdh.vir ig nia.gov.
Matthew Cloud, Environmental Health Specialist Senior
4fl� fj,�m tzey
411 � �C� Ag A
_ RECORD ^E INSPECTION SEWAGE DISP` "'4 ;y
KWJ
Date Case No.
Owner — .. Addres " Phone
f (Mailing Addre-
Oceupant Address Ph
Exact Location
of Premises —,
one
(Mailing Address)
WATER SUPPLY INSPECTION
Installed According to Permit Design: ❑ Yes ❑ No. Distance to Nearest House Sewer feet. Distance to Nearest Sewage
Disposal System —feet. . JUse Form LHS -143 for Detailed Inspection of Water Supply Reference Materials.)
(1)
(2)
(3)
(4,
(5)
SEWAGE DISPOSAL SYSTEM -INSPECTION
LOCATION:
Alloted Area A4pquiate-:,P1-WZ/es ❑ No. Distance from near-
est: Lot Line eet._Trees _/0 feet.
Water Supplies feet. _Buildings feet.
INSTALLATION AND DESIGN:
Installed According to Permit Design: ' Yes ❑ No
Have Additional Household Appliances Been Added? NOT on
Permit: ❑ Auto asher ❑ Garbage Disposal
❑ Other�_e-�
(Describe)
SOIL CONDITION:
Are there soil conditions now evident which indic syste
may be unsatisfactory as designed: i i Yes J�m
o. If Yes,
show adjustments required under "Remarks" below.
HOUSE SEW INE: . . -...
Installed-fYs No' Type of material:
�-ze *�" ruches.
SEPTIC TANK:
Constructed of
ind of Material)
Inside Dimensions- Length feet. Width _feet.
Liquid Depth feet. Depth of Air Space nehes.
Inside Fittings comply with requirements: es ❑ No.
(6) VDISTRIUTION BOX:
ht and equal surcharge to each line by Water Test:❑ No. Distribution Box provided with
(Number)
extra outlets for future use.
(7) SUB -SURFACE ABSORPTION IELD:
m
Total Area in Bottoof itchef�A� square feet
Number of Ditches _Len <rt of Ditches feet.
Grade of Ditches. inimum f Inches per 100 feet.
Maximum fa _ inches per 10_ 62t. Has system been
checked by instruments (L ti 1) es [] No
Type Aggregate Used
Depth of Aggregate Under Tile inches
Total Depth of Aggregate inches
Depth of Backfill Over Aggregate - inches
(S) SURFACE DRAINAGE:
Storm Drains from House and Ba ent Flowing Away from
Sub -Surface Drainage Field: Y ❑ No. Was Surface
Drainage Required: ❑ Yes o. If Yes, has this been
provided: .❑ Yes ❑ No. Has area been drair_y lower-
ing Ground Water Table: ❑ Yes ❑ No ;at auired,
(9) Are follow-up inspections necessary: ❑ Yes o
Septic Tams
Contractor • • _ft,
Address Phone
This System (Is) +r-cfCMp.proved by =-^f Health Department.
With proper maintenance, approved systems may be expected to function satisfactorily, provided no overloading or physical dam-
age occurs to the system. Remarks:
Date
Date
Date
Date
Virginia Department of Health
LHS - 141 11-57
Approved
Approved
Approved
(Sault pan)
(Health Director)
(Advisory Sanitarian)
(Reviewing Authority —Other Agency)
., .,. u/u' ✓i.:`vtlluE �iYSTEMS
Dat Case No.
Address Phone
-
Add
ai ing s
Occupant � Address
Mailing Address)Phone
Exact Location �n
of Premises
Subdivision, Street of oad ame, Section o of o.) ~ s A f
OWNERSIRES TO
WNSTALL FOR
❑ REPAIR welling El. ❑�r Supply System El Water Supply System
ewage Disposal S stem Actual Or Dotenti.l Bedrooms
Y ❑ Sewage Disposal System Con, , ,rt
1 wastes --_Actual or estimated Water
El Septic Tank S c Tank gal• per day Automatic Washing Machi
Health Department recommen 2 es " ❑ es No.
o Garbage Disposal unit Ydi-
DETAILS OF RECOMMENDED SYSTEMS
(1) WATER SUPPLYatioa o be approved by Sanitarian. Type
ElDrilled Well D. z -i1 ❑ Bored Well C1 Dag Well
El Other Cased
feet.
Casing to be property sealed and vented if necessary. Casing to extend
at least 6 inches above pump room floor. Grouted feet. All sur-
face 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.
(2) SOIL STUDY Naturally drained, s• ' able -1by es ❑ No
Technical Classification a sa
Rough Classification ❑Sandy �2;. ed❑ Clay El Pipe Clay.
Percolation Test required ❑ Yes o. Rate
Minutes per inch. "Depth of Water Table """""`""°`
�` (Est----imaz dj feet
Surface drainage required ❑ Yes L4 Area Der' inage by
L,awering Ground Water Table required E] Yes " ° o`
(3) DE LS OF CON TRUCTION Watertight Septic Tank of
Inside Dimensions Length {eet.
(Kind of Material)
Width 4 feet, Liquid Depth feet.
Air Space Depth of
feet. Li hid Capacity/gallons.
S E
(4) HOUSE =LINE _
inches. Type of material
requiredistance from Water Supply
z�-feet.
(5) SUBSURFACE ABSORPTION FIELD Distribution Box required.
Ditches of equal len th required. ,
Number of qua feet required
required roken Stone Type aggregate
i2 inches to 2112 incheVDe tth of
Slag. Size range from
P ggregate from base of tile to
bottom of ditches inches.
Total aggregate must equal minimum depth o inches or more.
Soil Cover over the not to exceed
inches: Distance from
Sewage Disposal S stem to the nearest point of a Water Suppl
et. y
S
h Sketch of Premises Ystem will be fe
lincluding adjacent properties if pertinent, Showing Location of Lot Line,
Trees, and Other Possible Sources of Con,ton of Water Supplies, by Indicating Distances andSlope
Water Supplies, Sewage Disposal Sys -
regard to one another.
feet
Plow ONn 7 or his agent must notify-
-s ready for ion o then. if any Sewaaga Disposal S Siem, or pai^; tnereal, is �✓' "before Ilealtnspectrt byt, P ilea, d �itr, '� j` a }r
-at t12� diPe CliaII of the I'ieairh Director "'---- �"�-3- l -j en 1n t3�j2i�OTg
or his ag r'. CONDITIONS DISici�lERZD D1JD'i� 1PfSTALLA'ed by MAY RE n Dapa � nt, , shall be uncovered
7 Ss'G\T, Changes frons above specifications
rage!', ire llealtn Deo art& ent approval before being made.
Based on the above information, the undersigned recommends that this oermit be issued. Ql BL A JUST'+l 1dTS Or SYSTEM
"-alih
Date Approvedq4,Reviewing Authority) —D nedLDS - 121 Rev. 11-57 Diracior)
Virginia State Department of health
r RECORD OT, i
ass INSTALLATION r '
yaw :rr PAIRS TO OI I3 II�ISTALLATION _
�:ttP OR OTHER!
Q: CONTRACTOR F`
TIONi 3`i ...I L d
ubdi n
*'Single Dwelling Unit
LOT Ste: f Width
'apt-. = P'. sr,: -aur• 14: &an--
SEWAGE DISPOSAL: 1
.40
., ._,.;Co ty _QF YI U a ty
ADDRESS'S.# a
describe
utomatic Laundry Machine—Yes '
DESIGN QP SYSTEM House Sewer Pipe—Size
Tank capacity Gallons; Tank dimensions ' ��
eiagth fr.°Wl€tlr ft Depth
Subsurface, drainage; Number of ditches ) oca
; m .. drainage
I "
..�. .Sq
ft.
INSPECTION FINDINGS
-(1) LOCATION: Lot size adequate es Na inti system (5a) DRAINAGE FIELD: Total lenge ditcFies feet '
accepted distance from water supply—, Yes "•� Properly,-Alf-Oltches of ual length es
M located relative td •fiFoperty." lanes buildings etc. ' es ❑ Na. Dept ft Properlq locate
_ _, er of rhes of poper grade Q Ye"s Q No itches laid—Q'6 dot se to s
ottom
(3) SbII CONDITION `Naturally drained and suitable bt Yes I �.. Yes Q No. P .
v ` Io 'Suflliei$t surface drarnage" tiitclies .provided Yesr Iia _.... _
Percolation tests iiiad'e [ -Yes ^ ]" o. Acceptable : ap- is "Q'Yes (5b) DRAINAGE FIELB (M als, 'ete ): -Open joints protected onto
❑ No with approved steps Yes Q No Approved filt aterial es
°` ❑ No. -Depth of filter material under
tile -
(3), SEPTIC TANK Installed accor<din Gopermtt n �Yaus� .Iua ilt¢r tcsr�a lee 6, _ c shim Z: to'Olttje a ( Hyl
Appeoved construc£ian for ,water, ss,. .
fixtures edrn y with requirements Yes Q 1 mrm' &rains from (t5e . DRAINSOfE, Mithb Alrxdrng) Storni cfira` from liou§e and baser`
house and basements 11 'n, iikt' r ori tank Yes Flo Trees, meet flowing away from drarnage field. es No. Ditches prop
:i etc::-vfiitn"T'lk fe t of�_,tamF'- No back--sh4ked;nci.*>rte-agraded
Yes = d er e v n � d •3
(4) D ATION BOA; �F ater(i ht and e tial surchar e 6 ter_Test (6) :DO THE ABOVE DE EC JI
. a - CONSTRUCTION WARRANT} iii_- u
Yes Q- IVo Inlets and outlets c ed tightly i eco '-jEETLOI�T�T es o .. _a»» -m W- 4;-
- Aileguate nuiml�er of 'extra' outlets Yes �" Na Separr lit Eines (7). IS . A FOLLOW -IJP HEINSPECTIO el `
connected to outlets and leading into subsurface ditches . • Q No, . 14 NECESSARY2 ,U Yes
Surcharge lines graded to l" or more to`10 feet length" "es ❑ No. f
REMARKS: y
a -j
B on• the above information this is to certify that this system (has) (aha Wt,) been located and installed according to Local ounty
State the
ements. system requires roper . use and adequate maintenance.
�,�`�
Date
,I_ . Signed "
(Inspector)
Title
Signed
(Reviewing Official)
s (Title)
With proper maintenance and avoidance of overloading this system can be expected to -function satisfactorily, if no
physical damage occurs to any part of the system and favorable soil conditions' continue.
Follow-ups: DatP
-,
Va. State Depf. of biealrh
LHS -141=50i+3