015253899_clearances - Laserfiche WebLink

�(t ca EHS Day Wed, Date Time 2ADDITION CHECK / ❑BUILDING CLEARANCE COUNTY OF LOUDOUN ZONING/ENVIRONMENTAL HEALTHBUILDING CLEARANCE EVALUATION REQUEST (maybe completed b)y /Z1 )m r Buil`ddin(g)) PIN: pZ:J 3 % I LCTM: / N o2 / Date Received: BOCA App. # T 9 0) �j 1 000 Building Permit # B Applicant: Owner: Please Call ❑ Applicant or ❑ Owner to Schedule a Type of Project: BR App. #T-/ Phone: Phone: ------------------------------------------------------------------------------------------------------------------------------------ ❑ Change of Use /Other ❑ New Construction X Addition or Remodeling (No Building Permit) (Building Permit (Building Permit Clearance Required) Clearance Required) ------------------------------------------------------------------------------------------------------------------------------------- CLEARANCE EVALUATION RESULTS (completed by Environmental Health) Water Supply: ❑ A well has been drilled and tested in accordance with Chapter 1040 of the Loudoun County Codified Ordinance (Permit # ). ❑ The property is served by a public water supply. The addition of the project referenced above has no impact on existin water supplies in the immediate area. C 6 6 WA'✓pE2 RtOPAVYA� -� Lcnj F' E ❑ Existing supply appears to be satisfactory. Sewage Disposal System: ❑ A permit has been issued to construct a sewage disposal system (Permit # # of Bedrooms ) The property is served by public sewer. ❑ The addition of the project referenced above has no impact on existing sewage disposal systems in the immediate area. ❑ Existing systems appear to be satisfactory. Building Zoning Permit Clearance > Approved /OK to clear ❑ Approved with conditions ❑ Hold Date: ❑ Off Hold Date: ❑ Denied (Changes of Use Application denied after 60 days, if no activity) Conditions /Reasons: Must meetall! qu setback distanoesto well and sewa egedisposalsystems. Environmental Health Specialist: pc: Residential Plans Review, Building nd Development ( ifspecial conditions apply toconstnxctiionofthestn .x(ize)