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LOUDOUN COUNTY HEALTH DEPARTMENT '(,�►') 1 �� <br /> Office use: Received .01'_I D t��:r n 2015 FEE PAID LvrES ❑❑NO APPLICATION# I (f• 91/ �AOtta h!ecei Receipt) <br /> p) <br /> AOSE Submi I YES L-41 0 Sewage Disposal System> 1000 GPD YES NO <br /> 171i5 �(5 <br /> APPLICATION FOR: a SEWAGE DISPOSAL a WELL PERMIT a ERTIFICATION LETTER <br /> P SEPTIC REPAIR ❑WELL/SEPTIC ABANDONMENT LI ADDITION DEMO <br /> C BUILDING RENOVATION E MINOR REPAIR 7 PUMP AND HAUL <br /> n I(- Betterment Loan Eligibility($50.00 fee) <br /> APPLICANT N w�c `— f (d)r. "5)‘�� HOME TELEPHONE �7 -7 <br /> MAILING ADDRESS O IS L5 St eZEEEkW . 1.(- 1-071) OFFICE TELEPHONE .o2_.72• j-1 / O <br /> Wa$ 6j-tm V�i Gv E-Mail Nati-4--ak-1.@veil i3An •- <br /> OWNER t0"T I ��r� r� '1^I TELEPHONE 7---'°1•7 4+1-7 D <br /> MAILING ADDRESS gig I 3 5 list 151e,(4150 E-Mail <br /> wa,/14\11W .131( 1 Z0oo( <br /> EXACT LOCATION(GIVE DIRECTIONS FROM LEESBURG) 3(8 5twargace..,5 c ,U - Zz &G <br /> PROPERTY IDENTIFICATION NUMBER: SEC. (09 ALPHA DC BLOCK LOT Lt 1' OO —�'J' D6 <br /> (IF APPLICABLE) NAME OF SUBDIVISION: // PIN#00 5 590(2 <br /> ACRES AND/OR SQ. FT. IN THIS PARCEL: 2-1 .144 ATTACH SITE PLAN (SKETCH) ON FORM PROVIDED. <br /> a, <br /> TYPE OF SEWAGE DISPOSAL: . . • ( 1-414-61441 wC/Y —) <br /> ti,6, , . ■ ■r.ss t,,+i/C. PROPOSED ✓PUBLIC SEWER SYSTEM: <br /> OVERLAY XISTING SEPTIC TANK DRAINFIELD SYSTEM <br /> REPAIR OTHER(DESCRIBE: ) <br /> "' ❑ INTERMITTENT <br /> TYPE OF WATER SUPPLY: <br /> ❑PROPOSED ❑PUBLIC-CENTRAL(SYSTEM NAME: ) <br /> VEXISTING IId'PRIVATE DRILLED WELL <br /> ❑OTHER(DESCRIBE: ) <br /> TYPE OF CONSTRUCTION: <br /> ❑ PROPOSED 'SINGLE FAMILY DWELLING <br /> XISTING ❑COMMERCIAL <br /> 1 f� REMODELING ❑OTHER I > ATTACH A COMPLETE DESCRIPTION <br /> , OF ALL ACTIVITIES-INCLUDE N0 OF <br /> jII? /7l �`1„l . ;l _ (D CRIBS) (DESCRIBE) �J PERTINENT INFORMATION. <br /> ETC, LOTHER <br /> if application is for an a►a itio+ : CONSTRUCTION INFORMATION: <br /> Increase waste load? YE NO Number of marketable bedrooms <br /> Extending water? YES NO Will foundation be chemically treated for termites ❑ YES - NO <br /> Extending sewer? YES NO Will plumbing fixtures be installed in the basement ❑ YES NO <br /> Related Building Permit # <br /> *Is addition properly staked'? DYES j NO *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 V NO <br /> IF APPLICABLE, HAS THIS PROPERTY BEEN PREVIOUSLY EXAMINED BY THE HEALTH DEPARTMENT'? "NO 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 <br /> SEE THE TOPOGRAPHY. I GIVE PERMISSION TO THE DEPARTMENT TO ENTER THE PROPERTY D ,SCRIBED FOR THE <br /> PURPOSE OF PROCESSING THIS APPLICATION <br /> r IF THE APPLICANT IS OTHER THAN THE LEGAL OWNER OF LEGAL OWNE' e.' w! __e/ L•i k • AL--,_ <br /> THE PROPERTY AT THE TIME APPLICATION IS MADE.THEN (Required Current Legal Owner) <br /> THE LEGAL OWNER MUST SIGN,THEREBY GIVING CONSENT P <br /> TO THE AGENTS OF THE COUNTY TO ENTER ONTO THE O 4 (5 <br /> PROPERTY AND MAKE SUCH TESTS AS ARE NECESSARY DATE <br /> AND/OR REQUIRED. <br /> ATTACH SITE PLAN, FEE AND RETURN TO: LOUDOUN COUNTY HEALTH DEPARTMENT <br /> 1 HARRISON STREET,S.E., LEESBURG,VA 20177 <br /> REV.September 3,2013 <br />