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05 -07 - 99 10:19 LOUDOUN DEPT 01' IIEAL1I1 <br />* For Department Use Onl <br />t'UU UL' <br />y <br />Caanor':"Ith of Virginia <br />loudoJ' County Department of Health <br />P.Q. 1'lox 7nno, 2nd Floor <br />Leesburg, Virginia, 20177 <br />(703)777 -0234, 478.8408 (metro) <br />Health Depart.ID# <br />Planimetric Hap N <br />Date Recd and Accepted C. -i�: <br />Date Permit Hailed <br />Commonwealth of Virginia, County of Loudoun <br />Application for a�e 1 Abandonment Permit <br />_ue <br />. s0"up"w- <br />To Bo Completed by the Applicant <br />Owner l koMPS'�, L,. L.,G. Address 4'160 FLCKATI( VM01 kDM Phone V'l' jo <br />Jc 1 I (I- cltiu,YTA, 2ot5J- J <br />Agent T Mau _ Address _- 1 56 Phone_(_) AMC, <br />Directions to property ALGOI KIPS_ eV-VJ .• 6 (ZIG o LowE isl,Rnlo swo. 18MOL8gr LF� <br />W,06KMW �AKM L&N� p�KoPER <br />Subdivision Name N IA <br />other Property ID, Dimensions /Size Of Lot /Property <br />I� <br />Section <br />Alpha DC Block Lot <br />F L I F' - 10 A69" - 2641 PgociCmi <br />Other Application Information LAtk6"r kU VA, 1,UGG <br />1. Reason for ebondarmuent: New ta�nkk Location connection to pubtle sewer ,.�/ <br />Other Describe �xl�iW6 IS [�I�v Fr;MMC4 <br />I�6 � QniJio6v 1 NTb ur(s W t� t�K lu- Cbr WCtgV IS Pdo,� � AM 66t' <br />Existing Sewage Disposal System Gravity_ Pump low Pressure Other_ <br />11, Single Family Yes K No — Multifamily Yes _„_ No X <br />Number of Bedroom Number of Units <br />Ill. C®rrciat Use: Yes _ No x Describe: <br />�( <br />Corm+ereIaI /Wastewater Yes _ No /` 0 of Patrons R of employees <br />If yes, give volumes and describe <br />IV. Water Supply: Public private "'L Describe: RV- <br />tttach a site plan showing diomm lops of property, location of the septic tank and the drainfield, existing sta=tures and <br />iriveways, underground utilities, welts and springs within a 50 foot perimeter of the of the existing septic tank aryl <br />trainfield. Incoel owlicntian and site plans will pqt be accepted for proeessi . <br />'The property Imes and septic tank/drainfleld location are clearly marked , I give permission to the Department <br />fo enjetror� the property descrlbed for the purpose of processing this appllcatlon. <br />cure of owner /Agent <br />Date <br />for Official Use Only) <br />Date initial <br />Sfte Visit <br />Permit Issued <br />(Comments) <br />av_ 11/94 <br />septaban.app <br />M <br />Dtint from J—'* cosout �t <br />