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Office use: <br />MW <br />LOUDOUN COUNTY HEA TH DEPARTMENT -role e -rnto 6000l S2 <br />RECD AUG 0 8 20 ; an3� >� o� <br />Received by ate: FEE PAID p YES NO APPLICATION # ` 03 OOM3 <br />Attach Receipt) <br />xUSE submittal - YES <br />APPLICATION FOR: SE OSAL <br />SEPTIC REPAI <br />_. BUILDING RENOVATION <br />Disposal <br />a 1040 GPD -YES O P N <br />WELL PERMIT CERTIFICATION LETTER <br />ELUSEPTIC ABANDONMEN �O.CA / A ION <br />M{ R REPAIR LIMP AND HAUL <br />APPLICANTS JL,,► R <br />MAILING ADOR�9S.�} <br />,mil <br />OWNER�l <br />MAILING ADDRESS_ I C-r -zz-'F i <br />HOME TELEPHONE 111 <br />OFFICE TELEPHONE_ <br />E- Malla`ll���CAACZar,, >Y) <br />TELEPHONE c� - t7`� . C� f <br />E -Mall <br />6D_ Rs 11 I n�) D ;� �e_SV y� Z-0 ,�-, co -- <br />EXACT LOCATION (GIIVEE DIRECTIONS FROM <br />—+LEESBU�R`G`). A_�w 1 9 <br />v�'�T o t/ A j <br />� 1 t, .J lJ l G aJ ! ti9 C) A� <br />PROPERTY IDENTIFICATION NUMBER: SEC._ � ALPHA DC BLOCK L �); (y <br />(IF APPLICABLE) NAME OF SUBDIVISION: PIN <br />ACRES AND /OR SO. FT. IN THIS PARCEL:1,t5 'e- ATTACH SITE PLAN (SKETCH) ON FORM PROVIDED, <br />F SEWAGE DISPOSAL: <br />Z h,[ <br />y <br />TYPE OF WATER SUPPLY: <br />TYPE OF CONSTRUCTION: <br />PROPOSED PUBLIC SEWER (SYSTEM: <br />';4XIS7ING PEPTIC TANK DRAINFIELD SYSTEM <br />* ' MEPAIR WTHER ( DESCRIBE55, : } <br />,INTERMITTENT p �J <br />0f� <br />PROPOSED "PUBLIC- CENTRAL (SYSTEM NAME: ) <br />�XISTING KPRIVATE DRILLED WELL <br />OTHER (DESCRIBE: ) <br />PROPOSED <br />*EXISTING <br />I.. REMODELING <br />G=am (DESCRIBE) <br />If application is for an addition or a BOCA : <br />Increase waste load YES C+ NO <br />Extending water YES NO <br />Extending sewer YES NO <br />Related Building Permit # <br />7QiINGLE FAMILY DWELLING <br />COMMERCIAL ATTACH A COMPLETE DESCRIPTION <br />_ OTHER OF ALL (TIES - INCLUDE No. OF <br />(DESCRIBE) EIAPLOYEES.ETC..ANDALL07HBN <br />PERTINENT INFORMATION. <br />CONSTRUCTION INFORMATION: <br />Number of marketable bedrooms <br />Will foundation be chemically treated for termites ; YES " NO <br />Will plumbing fixtures be Installed in the basement YES NO <br />IF APPLICABLE, HAS THIS PROPERTY BEEN PREVIOUSLY EXAMINED BY THE HEALTH DEPARTMENT? NO ! ES <br />IF YES, EXPLAIN (GIVE CASE NUMBER, DATE, ETC.)t !3 CA �A <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 P OPERTY DESCRIBED FOR THE <br />PURPOSE OF PROCESSING THIS APPLICATION O <br />ti LA1Yvv,s21C.� <br />IF THE APPLICANT IS OTHER THAN THE LEGAL OWNER OF LEGAL OWNE p <br />THE PROPERTY AT THE TIME APPLICATION IS MADE, THEN 1 <br />THE LEGAL OWNER MUST SIGN, THEREBY GVINGCONSENT (Required Current Legia ner) <br />TO THE AGENTS OF THE COUNTY TO ENTER ONTO THE f <br />PROPERTY AND MAKE SUCH TESTS AS ARE NECESSARY DATE <br />ANDIOR AEGUIRED, <br />ATTACH SITE PLAN, FEE AND RETURN TO: LOUDOUN COUNTY HEALTH DEPARTMENT <br />1 HARRISON STREET, S.E., LEESBURG, VA 20177 <br />REV, August 6, 2008 <br />• FSM standards must be followed if the proposal is related to a subdivision appacataon. <br />t 00'i 0 0 A L5(i 0 6L E IJ I: {b'tl'1 }slsapeu Ifl I'' lad F i: r I � I07 <br />