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It - A NIT <br /> Loudoun C ounty Health Department <br /> /717 <br /> P.O. Box 7000 <br /> Leesburg VA 20177 -7000 <br /> Environmental Health Community Health <br /> Phone: 703 / 777 -0234 Phone: 703/777 -0236 <br /> Fax: 703/771 -5023 Fax: 703/ 771 -5393 <br /> Request for Operation Permit <br /> Date RequA MAR 01 201 <br /> Contact Name: AEI Telephone #: a6_ Cp Qj Sz <br /> Property Address: l c2 S L s4 tf (�{,ra,�� `�/L PIN: <br /> Required prior to obtaining an Operation Permit <br /> Water Sample (Bacteriological) (N /A for Public Water) <br /> 1. Water sample is collected after all plumbing in the house is complete and then sent to an approved lab. <br /> 2. Water sample is collected from an approved source prior to any treatment works. (Not from a pressure <br /> tank or frost free hydrant) <br /> 3. Water sample is tested for Chlorine at the time it is collected. (Residual 0.0) <br /> 4. Water sample certification statement is received by the Health artment. <br /> Sewage Disposal (N /A for ublic Sewer) <br /> 1. The final inspection is completed and approved. <br /> 2. The completion statement is signed by the contractor or his representative. <br /> 3. Pump sheet and curve must be submitted to the Health Department. <br /> 4. A signed PE or AOSE Designer Certification Statement must be submitted to the Health Department (if <br /> required). <br /> 5. An "as- built' drawing of the drain field and components must be located in the file. <br /> 6. An operation and maintenance contract is obtained or a relationship with a licensed operator is <br /> documented (if required). <br /> 7. The County Agreement must be recorded in the deed of the property (if required). <br /> 8. The Operations & Maintenance Manual must be located in the file (if required). <br /> 9. State Notice of Recordation is recorded (if required). <br /> ❖ The anticipated processing time for Operation Permit is 48 hours <br /> after receiving the required information listed above. <br /> This form is provided to assist you through the permit process and is not intended to address every detail of every <br /> project. Additional information not stated on this checklist may be required. <br /> G:\Health ServicesTormsTront Desk \OP Request 2011- 07- 12.docx Revised: 7/12/2011 <br />