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t <br /> A <br /> s IIY.,, <br /> DIVISION OF ENVIRONMENTAL HEALTH ,V),11.11 <br /> LOUDOUN COUNTY HEALTH DEPARTMENT 1 �! <br /> 209 GIBSON ROAD, NW. . <br /> LEESBURG, VA. 22075 <br /> (703) 777-0234 Metro 478-1850 Ext. 234 t4 <br /> APPLICATION Department use only <br /> Request* // -gg Area#: <br /> Fee( ) #2/ .&ie) //6. ,n <br /> For Evaluation of existing water Receipt number / <br /> and/or sewage disposal systems. Reed by ...01/1 ` Date y�i l� <br /> Tax Map 5 (&)77 <br /> PIN # <br /> PL SE PRINT OR TYPE <br /> NOTE: Make checks payable to: County of Loudoun <br /> _ 3 <br /> Proposed Settlement Date � r t, + Transfer . Refinance? I7 <br /> II Property .i„ tl ,r? <br /> Address ;� Sebdivisio Sec S--7 Lot ii <br /> Direr io ut\ i 3`� # .ale ��rowl til S c IA - tc. \"_.\ifc.r.t� ( , ,c. Kli ) <br /> Owner: �� C.., -& _ Pho :)� -..b' C (0) y 3 V 91-00 <br /> Address: <br /> (:)41 1Evaluation Requested by: P e. HOS (0) <br /> Send Report to: Ctc_.' n' 1 1 C' — V.)b -' S kA L 1 a Cr' ti <br /> Address: _� 1 \ \, 1. \L.\ i' <br /> USE BACK OF THIS PAGE IF NECESSARY TO C.aMP ETE INFORMATION (Please Type or Clearly Print) /� <br /> 1 - Describe any history of a malfunction of the sewage disposal system (i.e. backup, pump malfunction, etc.) l roNw_-- <br /> 2 - Date Septic tank last pumped: 3 - Number of bedrooms ;:k 4 - Approx. age of septic system t0‘1th-S <br /> 5 - Is an automatic clothes washer or hook-up installed? ye> 6 - Is there a garbage disposal installed? (\lm <br /> i 7 - a. Has the dwelling been occupied under usual and customary waste load conditions for the past 30 days? <br /> b. By how many people? 3 <br /> 8 - Is there discharge of laundry, kitchen, or other waste on top of the ground surface? no <br /> If yes, explain: <br /> 9 Dwelling is connected to: WELL q/ PUBLIC WATER DIOTHER LI (Answer 10, 11 if well or other is checked) <br /> 10 - Describe any history of well problems (insufficient water, muddy water, etc.) <br /> 11 - Circle an form of water treatment (pH control, filters, softening, iron„ sulphur, chlorination, ultra-violet) <br /> k\C9!"`L--- <br /> The following information must be supplied by the owner. (Complete all blanks) <br /> I CERTIFY THE INFO AATION ON THII„FORM AS SUPPLIED BY THE OWNER AND IS CORRECT TO THE BEST OF MY KNOWLEDGE: <br /> SIGNATURE `6-e � % ( PRINT NAME �e_ �:�.-h \ctir�c,•'11 c'1 <br /> OWNER q/ AGENT El <br /> i NOTE:Please attach copy of listing if available from realtor and copies of any previous records on the water supply and sewage disposal <br /> system. <br />