REDACTED WIIN-12_W&WA replacement well permit VDH (1).pdf

VDH Design Well Permit Well and Sewage Contractors: Please notify Health Department 48 hours prior to installation to arrange for inspection

RE: ___________________________________________

Tax Map/GPIN: _____________________________

HDID: _________________________ Reserve: _____ % reserve area provided

System Capacity: ______________________________

Dear Applicant :

This letter and the attached drawings, specifications, and calculations (___ pages) dated _____________, constitute your permit to install a sewage disposal system and well if applicable on the property referenced above.

The well location and construction were certified by __________________________________ as substantially complying with the Board of Health’s regulations (and local ordinances if the locality has authorized the local health department to accept private evaluations for compliance with local ordinances). This permit is issued in reliance upon that certification. VDH hereby recognizes that the site conditions acknowledged by this permit are suitable for the installation of a private well. The attached drawing shows the approved area for the private well; there are additional records on file with the Pittsylvania County Health Department pertaining to this permit, including the Site and Soil Evaluation Report. This construction permit is null and void if any substantial physical change in the soil or site conditions occurs where a sewage disposal system is to be located.

If modifications or revisions are necessary between now and when you construct your dwelling, please contact VDH who performed the evaluation and design on which this permit is based. Should revisions be necessary during construction, your contractor should consult with VDH that submitted the site evaluation or site evaluation and design. VDH is authorized to make minor adjustments in the location or design of the system at the time of construction provided adequate documentation is provided to the Pittsylvania County Health Department.

Level Review

Pittsylvania County Health Department Drawer 369

Chatham, Virginia 24531

(434) 433-3520 Voice

(434) 432-7764 Fax

Corey Sutphin, VDH EHS

6/9/2025

236 Primitive Baptist Road

Dry Fork, VA 24549

SWAP replacement well 236 Primitive Baptist Rd.

1461-74-2351/3373

171-25-0119 N/A

300GPD (2-bedroom)

6/6/2025

Tax Map/GPIN: ________________________ Page 2 of 3

HDID: ___________________________

This Construction Permit is null and void if conditions are changed from those shown on your application or if conditions are changed from those shown on the attached construction drawings, specifications, and calculations. VDH may revoke or modify any permit if, at a later date, it finds that the site and soil conditions and/or design do not substantially comply with the Private Well Regulations, 12 VAC 5-630-20 et seq., or if the system would threaten public health or the environment.

This permit approval has been issued in accordance with applicable regulations based on the information and materials provided at the time of application. There may be other local, state, or federal laws or regulations that apply to the proposed construction of this onsite sewage system. The owner is responsible at all times for complying with all applicable local, state, and federal laws and regulations.

This construction permit is transferrable until expired or deemed null and void. A permit transfer form may be found on the VDH website at http://www.vdh.virginia.gov/environmental-health/gmp-2015-01-forms/ .

If you have any questions, please contact me.

This permit expires: ____________________________

Sincerely, Corey Sutphin Environmental Health Specialist Pittsylvania County Health Department

CC: ____________________________ VDH

Corey Sutphin

1461-74-2351/3373

171-25-0119

12/9/2026

Tax Map/GPIN #: _____________________________ Page 3 of 3

HDID#: _______________________________

YOUR WELL PERMIT WILL ALSO NEED

Your well must have satisfactory inspection results after installation. Please give the Health Department several days notice to schedule this inspection before your Operation Permit will be requested.

The Health Department must receive a copy of your water sample test result being negative/satisfactory for coliform bacteria. You are responsible for performing this test and ensuring the results are received at the Health Department

Please ensure that your Well Driller submits a Uniform Water Well Completion Statement or GW-2 to the Health Department, including documentation of a proper well abandonment if required by permit Allow 5 business days after the last piece of documentation is received for the Operation Permit to be issued. To avoid delays, clearly label each piece of documentation with the property Tax Map/GPIN number and HDID number shown above and on your construction permit.

Please note that due to individual circumstances of your permit there may be additional required items not covered by this checklist.

If you have any questions about any of the items on this list, please do not hesitate to contact the Pittsylvania County Health Department at (434) 434-3520.

1461-74-2351/3373

171-25-0119