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LOUDOUN COUNTY HEALTH D PARTMENT <br /> lir <br /> Office use: Received by Dg_ 01 9(115 FEE PAID YTES G NO APPLICATION#1 ��200Vtttach Receipt) <br /> AOSE Submittal 0 YES 7,NO ' Sewage Disposal System>1000 GPD ❑YES NO <br /> APPLICATION FOR: ❑ SEWAGE DISPOSAL ❑WELL PERMIT 0 CERTIFICATION LETTER <br /> ❑SEPTIC REPAIR ❑WELL/SEPTIC ABANDONMENT ADDITION /DEMO <br /> ❑ BUILDING RENOVATION 0 MINOR REPAIR ❑ PUMP AND HAUL <br /> ❑ RENEWABLE OP 0 Betterment Loan Eligibility($50.00 fee) <br /> PLICANT /CL (7 a-----C- ME TELEPHONE 70 3 YG1- 5 7 <br /> AILING ADDRESS // ?,1i &4,J FFICE TELEPHONE 703 ZO9--5 9'rz.. C e‘t <br /> .67-6- re L/kJGt- VA 2a/6 s-- E-Mail /�.e i . ec/ (0-Pc706.S. ec/J <br /> NER /<e e -c K ELEPHONE 7o5 ^ ‘-Sim-5 j , - -7 <br /> AILING ADDRESS /( (`)I/' LA Ai �E-Mail <br /> 5'c;fe c //J V1 Z o/4 S— /� <br /> 4;PLEASE PROVIDE DRIVING DIRECTIONS FROM LEESBURG (r�C T 7 f A ST - Z vw 1O 1140 V)64-) Rd <br /> L mr, 0-4k L A AI E . // /5 --(3r51 A o U 5 P o,., e->f -I-- <br /> PROPERTY IDENTIFICATION NUMBER: SEC. S'I ALPHA C._ DCJZ BLOCK LOT ( 2- / <br /> (IF APPLICABLE) NAME OF SUBDIVISION: PIN# C 12:45-O g 5 G <br /> ACRES AND/OR SQ. FT. IN THIS PARCEL: ATTACH SITE PLAN (SKETCH) ON FORM PROVIDED. <br /> TYPE OF SEWAGE DISPOSAL: (Check all that apply) (Check all that apply) <br /> PROPOSED PUBLIC SEWER(SYSTEM: ) <br /> ^EXISTING 14..EPTIC TANK DRAINFIELD SYSTEM <br /> REPAIR ,OTHER(DESCRIBE: ) <br /> INTERMITTENT <br /> TYPE OF WATER SUPPLY: (Check all that apply) (Check all that apply) <br /> PROPOSED , PUBLIC-CENTRAL(SYSTEM NAME: ) <br /> 'EXISTING ■PRIVATE DRILLED WELL <br /> OTHER (DESCRIBE: ) <br /> TYPE OF CONSTRUCTION: (Check all that apply) (Check all that apply) <br /> 'PROPOSED SINGLE FAMILY DWELLING <br /> i-r w— EXISTING COMMERCIAL I > ATTACH A COMPLETE DESCRIPTION <br /> �- [I REMODELING OTHER OF ALL ACTIVITIES-A INCLUDE NO OF <br /> �� Q ;�7,) (D �tIBE) (DESCRIBE) r-> EMPLOYEES.ETC ND ALL OTHER <br /> L+T A SC(� �J V' PERTINENT INFORMATION. <br /> If application is for an addition or a BOCA : CONSTRUCTION INFORMATION: <br /> Increase waste load? 0 YES K NO Number of marketable bedrooms3 <br /> Extending water? 0 YES?<" NO Will foundation be chemically treated for termites H YES ,<-)%10 <br /> Extending sewer? 0 YES )( NO Will plumbing fixtures be installed in the basement I I YES NO <br /> Related Building Permit # <br /> *Is addition properly staked? "YES I: 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 LI NO <br /> IF APPLICABLE, HAS THIS PROPERTY BEEN PREVIOUSLY EXAMINED BY THE HEALTH DEPARTMENT? , NO 4ES <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 DESCRIBED FOR THE <br /> PURPOSE OF PROCESSING THIS APPLICATION. <br /> 1Z5_____ <br /> IF THE APPLICANT IS OTHER THAN THE LEGAL OWNER OF L OWNS <br /> THE PROPERTY AT THE TIME APPLICATION IS MADE,THEN ( equ d Curren I Owner <br /> THE LEGAL OWNER MUST SIGN,THEREBY GIVING CONSENT <br /> TO THE AGENTS OF THE COUNTY TO ENTER ONTO THE <br /> PROPERTY AND MAKE SUCH TESTS AS ARE NECESSARY AT <br /> AND/OR REQUIRED. \V SCI' ' ED <br /> ATTACH SITE PLAN, FEE AND RETURN TO: LOUDOUN COUNTY HEALTH DEPAR 'ANT <br /> 1 HARRISON STREET,S.E., LEESBURG,VA 20177 REV.11/3/2015 <br />