Laserfiche WebLink
LOUDOUN COUNTY HEALTH DEPARTMENT Ok, OO of <br /> SEP 16 2016 <br /> Office use: Received by 73 Date: FEE PAID *ES ❑NO APPLICATION# (Attach Receipt) <br /> AOSE Submittal ❑YES 00 Sewage Disposal System>1000 GPD ❑YES I NO <br /> ;,,,/,- . I C.-i-,) <br /> APPLICATION FOR: ❑ SEWAGE DISPOSAL ❑WELL PERMIT ❑CERTIFICATION LETTER <br /> ❑ SEPTIC REPAIR (SR) ❑WELL ABANDONMENT y;ADDITION /DEMO <br /> ❑ MINOR REPAIR (MR) ❑ BUILDING RENOVATION ❑ PUMP AND HAUL <br /> `f ,, ❑SEPTIC ABANDONMENT ❑ RENEWABLE OP ❑ BETTERMENT LOAN <br /> APPLICANT <br /> Vi I ffii t <br /> V OCOOye HOME TELEPHONE ELIGIBILITY ($50.00 fee) <br /> MAILING ADDRESS 2- t he&J ��_( -c d OFFICE TELEPHONE 7�:3- 7V)-°*11:x' <br /> irlr04, VA -O �, E-MAIL Vra joy to, �hvd5,rw <br /> OWNER LLB/ v---le l 1- N� l I SSc - TELEPHONE <br /> MAILING ADDRESS Ci II Oc.k La74--�- E-MAIL <br /> I i i'dc\ 1/A- 2_O I(Ok-i �j ,(� y� <br /> **PLEASE PROVIDE DRIVING DIRECTIONS FROM LEESBURG •4- .q >� - Le--t- On f M i s"`L5 C i0_ <br /> Lel prn po J v`ew i L, an•i-o cDct.k 1 a ri e <br /> Property Address I I 6(k(L 1--a r) ' - J;,.- ) <br /> (IF APPLICABLE) NAME OF SUBDIVISION: AR).- rte` Lot# 1 2 PIN# 0/2-4/5-- (f�,5. <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 K SEPTIC TANK DRAINFIELD SYSTEM <br /> ❑REPAIR OTHER (DESCRIBE: ) <br /> 0 INTERMITTENT <br /> TYPE OF WATER SUPPLY: (Check all that apply) (Check all that apply) <br /> ❑PROPOSED Li PUBLIC-CENTRAL(SYSTEM NAME: ) <br /> bX EXISTING je PRIVATE DRILLED WELL <br /> LE OTHER (DESCRIBE: ) <br /> TYPE OF CONSTRUCTION: (Check all that apply) (Check all that apply) <br /> 1cPROPOSED 'p SINGLE FAMILY DWELLING <br /> ,( ( VEXISTING LI COMMERCIAL , <br /> jUr•/-43(? (.�U I f(CJ�4'" > ATTACH A COMPLETE DESCRIPTION <br /> " J REMODELING C:OTHER I OF ALL ACTIVITIES-INCLUDENO OF <br /> f— - (DESCRIBE) (DESCRIBE) > EMPLOYEES,ETCANDALLOTHER <br /> ��� STC�l{ cu id n• PERTINENT INFORMATION. <br /> If application is for an addition or a BOCA: CONSTRUCTION INFORMATION: <br /> Increase waste load? J YES It NO Number of marketable bedrooms 0- <br /> Extending water? J YES .--NO Will foundation be chemically treated for termites 1 YES )4 NO <br /> Extending sewer? ri YES NO Will plumbing fixtures be installed in the basement ' YES }-NO <br /> Related Building Permit# <br /> *Is addition properly staked? ❑ YES 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?ITT(YES NO (t'\o,c'-)./ ` .e+c h P �-- 2L_ i/y <br /> IF APPLICABLE, HAS THIS PROPERTY BEEN PREVIOUSLY EXAMINED BY THE HEALTH DEPARTMENT? [ NO XYES <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 E ER THE PROPER, DESCRIBED FOR THE <br /> PURPOSE OF PROCESSING THIS APPLICATION. <br /> IF THE APPLICANT IS OTHER THAN THE LEGAL OWNER OF LEGAL O / � <br /> THE PROPERTY AT THE TIME APPLICATION IS MADE,THEN (Required C re t Legal 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 DATE ifr, <br /> AND/OR REQUIRED. <br /> ATTACH SITE PLAN, FEE AND RETURN TO: LOUDOUN COUNTY HEALTH DEPARTMENT <br /> P.O. Box 7000 MSC#68 Leesburg, VA 20177-7000 REV.5/26/2016 <br />