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LOUDOUN COUNTY HEALTH DEPARTMENT I 1 Uo UO <br /> R . AUG 21 2020 Arica:+tor\ <br /> Office use: Received by Date: FEE PAID GrYES U NO (Check/Cash Only) <br /> Application# (Attach Receipt) AOSE Submittal YES i;1.No-Sewage Disposal System>1000 GPD i YES H NO <br /> APPLICATION FOR: <br /> [J SEWAGE DISPOSAL 0 WELL-PERMIT-G 4._fr-y ' i CERTIFICATION LETTER <br /> Cl SEPTIC REPAIR(SR) Li WELL ABANDONMENT U ADDITION/DEMO <br /> D MINOR REPAIR (MR) Ui BUILDING RENOVATION 0 EMERGENCY PUMP AND HAUL <br /> 0 SEPTIC ABANDONMENT ;VOLUNTARY UPGRADE ATHERsaa4)-4 / d <br /> APPLICANT /)_...e-P".� HOME TELEPHONE 76°,3-- Q[s- _2 S_ <br /> MAILING ADDRESS ///3 e7,S L S L OFFICE TELEPHONE 76 3 3 sl:c _2 S 2,5 <br /> I V -e, li 'Lt- K"lt 22-/?0 E-MAI i ' - R asL, CGyy; <br /> OWNERTQH n Sc_ et TELEPHONE 7/93 -6 2,3'' • cF-9, <br /> MAILING ADDRESS/P I f Lake E-MAIL()//U e <br /> Ste tJ/hV/k o e&y <br /> *"PLEASE PROVIDE DRIVING DIRE'TIONS FROM LEESBURG <br /> Property Address ! D 10 -A 2a e-- r�ii' f',, 3 t o tJIA1 _ )/ 1 2- 0I W 4/1 <br /> (IF APPLICABLE)NAME OF SUBDIVISION: 1 tel, )t0/!4 Qcit�t'# 3 PIN# <br /> ACRES AND/OR SQ. FT. IN THIS PARCEL:5 to YOS ATTACH SITE PLAN(SKETCH)ON FORM PROVIDED. <br /> TYPE OF SEWAGE DISPOSAL: (Check all that apply) (Check all that apply) <br /> PROPOSED --PGBLIC SEWER(SYSTEM: ) <br /> .EXISTING SEPTIC TANK DRAINFIELD SYSTEM <br /> REPAIR OTHER(DESCRIBE: ) <br /> 'INTERMITTENT <br /> TYPE OF WATER SUPPLY: (Check all that apply) (Check all that apply) <br /> PROPOSED ❑PU -IC-CENTRAL(SYSTEM NAME: ) <br /> hvEXISTINGLI-PRIVATE DRILLED WELL <br /> [7 OTHER(DESCRIBE: ) <br /> TYPE OF CONSTRUCTION: (Check all that apply) (Ch ek all that apply) <br /> ' PROPOSED DINGLE FAMILY DWELLING <br /> WO <br /> UEXISTING ❑COMMERCIAL I <br /> > ATTACH A COMPLETE DESCRIPTION <br /> REMODELING ci OTHER OF ALL ACTIVITIES-INCLUDE NO.OF <br /> C i(DESCRIBE) (DESCRIBE) ' EMPLOYEES,ETC.,AND ALL OTHER <br /> PERTINENT INFORMATION. <br /> If application is for an addition or a BOCA: CONSTRUCTION INFORMATION: <br /> Increase waste load? I YES [I NO Number of marketable bedrooms <br /> Extending water? YES LI NO Will foundation be chemically treated for termites 1 YES 17 NO <br /> Extending sewer? • YES H NO Will plumbing fixtures be installed in the basement I YES 11 NO <br /> Related Building Permit# <br /> *Is addition properly staked? YES O *If no, please stake within 24 hours from date of application. <br /> Would you like to be present at the time of the site visit? , YES 0 NO // <br /> IF APPLICABLE, HAS THIS PROPERTY BEEN PREVIOUSLY EXAMINED BY THE HEALTH DEPARTMENT? ,-"K-.0 YES <br /> IF YES, EXPLAIN(GIVE CASE NUMBER, DATE, ETC.) <br /> THE PROPERTY LINES AND BUILDING LOCATION ARE CLEARLY MARKED AND THE PROPERTY IS SUFFICIENTLY VISIBLE TO SEE THE <br /> TOPOGRAPHY. I GIVE PERMISSION TO THE DEPARTMENT TO ENTER THE PROPERTY DESCRIBED FOR THE PURPOS,E OF PROCESSING <br /> THIS APPLICATION. i// <br /> NEW OWNER TRANSFER YES . N/A <br /> IF THE APPLICANT IS OTHER THAN THE LEGAL OWNER OF <br /> THE PROPERTY AT THE TIME APPLICATION IS MADE,THEN LEGAL OWN ER� L�2 U1� <br /> THE LEGAL OWNER MUST SIGN,THEREBY GIVING CONSENT <br /> TO THE AGENTS OF THE COUNTY TO ENTER ONTO THE (Print name.Required urrent Legal Owner j��� <br /> / <br /> PROPERTY AND MAKE SUCH TESTS AS ARE NECESSARY l <br /> AND/OR REQUIRED. SIGNATURE ; / DATE <br /> 1 <br /> ATTACH SITE PLAN&SURVEY OR SURVEY WAIVER REQUEST,FEE AND RETURN TO: LOUDOUN COUNTY HEALTH DEPARTMENT <br /> P.O.Box 7000 MSC#68 Leesburg,VA 20177-7000 REV.2109/2018 <br />