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Commonwealth of Virginia for Department Use Only Health Depart.ID# 3 <br />Loudoun County Department of Health Planim>etric Hap # <br />P.O. Tim, 7000, 2nd Floor Date Recd and Accepted <br />Leesburg, Virginia, 20177 Date Permit Hailed <br />(703)777 -0234, 478 -8408 (Metro) <br />Commonwealth of Virginia, County of Loudoun w� �s <br />Application for a Septic Tank Abandonment Permit <br />To Bo Completed by the Applicant <br />Agent �S � _� 1 fl� <br />Directions to property <br />Subdivision Name <br />Other Property ID, Dimensions /Size Of Lot /Property <br />Other Application Information <br />Reason for alxridam3ent: New lank Location <br />Address %rj <br />ylle4ikla I IJ 1 i <br />Address <br />Section Alpha DC <br />l <br />Connection to publicvsewer <br />Other Describe <br />Existing Sewage Disposal System Gravity PLIT_ Low Pressure_ other <br />11. Single Family Yes '//�o _ Multifamily Yes _ No <br />Number of Bedrooms Number of Units <br />III. Coamercial Use: Yes _ No--Z Describe: <br />Commercial /Wastewater Yes _ No " of Patrons # of employees <br />If yes, give volumes and describe <br />IV. Water Supply: Public --rte Private Describe: <br />Phone ( ) <br />Phone(o� <br />Block Lot <br />Attach a site plan showing dioertsiorzs of property, location of the septic tonic and the drainfield, existing structures and <br />driveways, underground utilities, wells and springs within a 50 foot perimeter of the of the existing septic tank and <br />drainfield. Inccraptete applicatifxis arxi site plans will not be accented for processing. <br />The property lines and septic tank/drainfleld location are clearly marked . I give permission to the Department <br />to enter onto the property described for the purpose of processing this appllcatlon. <br />ignature of Owne /Agent ate <br />(for Official Use Only) <br />Site Visit <br />Permit Issued <br />(Comments) <br />Irev. 11/94 <br />a:septaban.app <br />Date Initial <br />Print from )ane'■ corrputet <br />