008152199 SEPTIC DENIAL - Laserfiche WebLink

) LOUDOUN COUNTY $ `' GENERAL APPLICATION FOR CONSTRUCTION - REMODELING APPLICANT HOME TELEPHONE MAILING ADDRESS OFFICE TELEPHONE OWNER TELEPHONE MAILING ADDRESS EXACT LOCATION (GIVE DIRECTIONS FROM LEESBURG) PROPERTY IDENTIFICATION NUMBER: SEC. PARCEL (AVAILABLE FROM COMM. OF REV.) (IF APPLICABLE) NAME OF SUBDIVISION: SEC. LOT ACRES AND /OR SQ.FT. IN THIS PARCEL: NUMBER OF ACRES IN PARENT TRACT FRONTAGE: CURRENT ZONING PREVIOUS SELL -OFFS GRADING: ❑ i ACRE OR LESS ❑ IN EXCESS OF i ACRE ATTACH TWO (2) COPIES OF A PLAT OF THE PROPERTY AND/OR OF THE PARENT TRACT SHOWING THE SELL -OFF. PLATS ARE NOT REQUIRED FOR PARCELS IN EXCESS OF 50 ACRES IF THEY ARE PARCELS OF RECORD AND THERE ARE NO SELL -OFFS. TYPE OF SEWAGE DISPOSAL: ❑ PROPOSED PUBLIC SEWER (SYSTEM:. ) ❑ EXISTING ❑ SEPTIC TANK DRAINFIELD SYSTEM , REr,E�VED El OTHER (DESCRIBE: TYPE OF WATER SUPPLY: 1919 'o 1 PROPOSED El PUBLIC-CENTRAL (SYSTEM: ±1�� ) r e ❑ EXISTING ED �, C° PRIVATE DRILLED WELL �. �„ ❑ OTHER (DESCRIBE: %out\ • TYPE OF CONSTRUCTION: 1±1 PROPOSED ] SINGLE FAMILY DWELLING ❑ EXISTING ❑ COMMERCIAL - ATTACH A COMPLETE DESCRIPTION i ❑ REMODELING ❑ OTHER OF ALL ACTIVITIES - INCLUDE N0. OF EMPLOYEES, ETC., AND t (DESCRIBE) ALL OTHER PERTINENT INFORMATION FIXTURES TO BE INSTALLED (INDICATE NUMBER) - IF NOT APPLICABLE INDICATE WITH N /A: KITCHEN SINKS DISHWASHING MACHINES TOILETS LAVATORY SINKS AUTO. CLOTHES WASHERS SHOWERS LAUNDRY TUBS GARBAGE DISPOSAL UNITS BATH TUBS NUMBER OF BEDROOMS NUMBER OF BATHROOMS KITCHEN ❑ NO OYES DINING ROOM ❑ NO ❑ YES LIVING ROOM ❑ NO OYES FAMILY /REC. ROOM ❑ NO OYES DEN ❑ NO OYES OTHER ROOMS ❑ NO OYES -o-EXPLAIN BASEMENT ❑ NO DYES ❑UNFINISHED ❑ FINISHED -4- DESCRIBE LIST FIXTURES TO BE INSTALLED IN BASEMENT IF APPLICABLE, HAS THIS PROPERTY BEEN PREVIOUSLY EXAMINED BY THE HEALTH DEPT. ❑ NO ❑ YES —� IF YES, EXPLAIN (GIVE CASE NUMBER, DATE, ETC.) IF THE APPLICANT IS OTHER THAN THE LEGAL OWNER OF THE PROPERTY AT THE APPLICANT SIGNATURE: TIME APPLICATION IS MADE, THEN THE LEGAL OWNER MUST SIGN, THEREBY cIV- DATE: ING CONSENT TO THE AGENTS OF THE COUNTY TO ENTER ONTO THE PROPERTY AND MAKE SUCH TESTS AS ARE NECESSARY LEGAL OWNER: AND /OR REQUIRED. DATE: (FOR OFFICIAL USE ONLY) HEALTH DEPT. APPROVAL REQUIRED ❑ NO ❑ YES THIS PROPERTY HAS BEEN REVIEWED OTHER APPROVAL REQUIRED BY THE ZONING OFFICE AND CON- FORMS TO THE ZONING REQUIREMENTS OF LOUDOUN COUNTY. ZONING CLEARANCE GRANTOR REMARKS: DATE: FEE PAID OYES ONO APPLICATION NUMBER: HEALTH DEPARTMENT COPY ___________AMMMEma ....,,,m111111111111111111i