002164791 CLEARANCES - Laserfiche WebLink

LOUDOUN COUNTY HEALTH DEPARTMENT Ma-i-tio/------u7(.40 Office use: Received t, .9 Date: ' FEE PAID aYES 0 NO APPLICATION C - 5o ac -- ( ttach Receipt) AOSE Submittal ❑YES Nsd' O Sewage Disposal System>1000 GPD OYES VINO / APPLICATION FOR: E SEWAGE DISPOSAL C WELL PERMIT ❑ CERTIFICATION LETTER ❑SEPTIC REPAIR (SR) ❑WELL ABANDONMENT 'ADDITION/DEMO ❑ MINOR REPAIR (MR) ❑ PUMP AND HAUL C SEPTIC ABANDONMENT CI RENEWABLE OP ❑ BETTERMENT LOAN APPLICANT /en�� //7G ELIGIBILITY($50.00 fee) HOME TELEPHONE MAILING ADDRESS /' OFFICE TELEPHONE 1 3- cP6'"/(ff; / g L i -1 /. 0/4- T E-M AIL 3;1 ES /i�� c //� ?.Cd1i _ OWNER IIMA 0119/1C- :, 07431Y QI,/"7 TELEPHONE 7 O3/p�-3-14?Y3 MAILING ADDRESS Inl .s/4 G-4 /e E-MAIL (717/70 ,} cePli sift' ,J1 LY, O/65 ""PLEASE PROVIDE DRIVING DIRECTIONS FROM LEESBURG 4T . - 7,6 G ,S7'01.61/J / /,c_,.."7- 0,-//) ,..c.,6-7)E CA G,6`F OK) kti G/4�7O,) /er 61-2 6/.4 e. --1'51 Property Address Mir .S7/7, fI /'G. (IF APPLICABLE) NAME OF SUBDIVISION: /Ci? C/9D,E� Lot# �,i /4 PIN# /)( 'S/ t -Ici ACRES AND/OR SQ. FT. IN THIS PARCEL: /5'/k ATTACH SITE PLAN (SKETCH) ON FORM PROVIDED. TYPE OF SEWAGE DISPOSAL: (Check all that apply) (Check all that apply) ❑PROPOSED PUBLIC SEWER(SYSTEM: _ )C i OUN t AINSIDE pEPAIIR G ❑OTHEIR TANK DIB INFIELD SYSTEM r%Ifr III AS/ ❑INTERMITTENT ) TYPE OF WATER SUPPLY: (Check all that apply) (Check all that apply) ❑PROPOSED _:PUBLIC-CENTRAL(SYSTEM NAME: ) ti•EXISTING .4PRIVATE DRILLED WELL ❑OTHER(DESCRIBE: ) TYPE OF CONSTRUCTION: (Check all that apply) (Check all that apply) ❑PROPOSED ttSINGLE FAMILY DWELLING ❑COMMERCIAL ,o;p/y/0/ ic,.i., Q4 ❑EXEIMSOTIDNEG LING > ATTACH ACO MPLETEDESCRIPTION ❑OTHER vf g (DESCRIBE) (DESCRIBE) F > OSOY EETCS ANAOT ER F 10 S /,-- /ii P2On7 >/ n • PERTINENT INFORMATION. If application is for an addition or a BOCA: CONSTRUCTION INFORMATION: Increase waste load? YES of NO Number of marketable bedrooms Extending water? • YES CIP NO Will foundation be chemically treated for termites YES I NO Extending sewer? YES Er NO Will plumbing fixtures be installed in the basement YES 'I NO Related Building Permit# `Is addition properly staked? _ YES ENO *If no, please stake within 24 hours from cate of application. Would you like to be present at the time of the site visit?": YES <NO IF APPLICABLE, HAS THIS PROPERTY BEEN PREVIOUSLY EXAMINED BY THE HEALTH DEPARTMENT? NO u YES IF YES, EXPLAIN (GIVE CASE NUMBER, DATE, ETC.) THE PROPERTY LINES AND BUILDING LOCATION ARE CLEARLY MARKED AND THE PROPERTY IS SUFFICIENTLY VISIBLE TO SEE THE TOPOGRAPHY. I GIVE PERMISSION TO THE DEPARTMENT TO ENTER THE PROPERTY DESCRI:;ED FOR THE PURPOSE OF PROCESSING THIS APPLICATION. ,1 ^ ,7 IF THE APPLICANT IS OTHER THAN THE LEGAL OWNER OF i THE PROPERTY AT THE TIME APPLICATION IS MADE,THEN LEGAL OWNER � � , THE LEGAL OWNER MUST SIGN,THEREBY GIVING CONSENT (Required Current L al Own r) Ztd2 TO THE AGENTS OF THE COUNTY TO ENTER ONTO THE PROPERTY AND MAKE SUCH TESTS AS ARE NECESSARY DATE l AND/OR REQUIRED. ATTACH SITE PLAN, FEE AND RETURN TO: LOUDOUN COUNTY HEALTH DEPARTMENT P.O. Box 7000 MSC#68 Leesburg,VA 20177-7000 REV.5/26/2016