---
type: document
title: RC Tank Permit Application Form 202211020903439653
file: ../RC Tank Permit Application Form_202211020903439653.pdf
tags:
  - Russell_County
  - Building_Department
docDate: null
contentType: application/pdf
contentLength: 184065
sha256sum: 4ed5b6f803478ade71963a8a59de5dcba7bfde9d19ddbce818cebff8d935f6a6
sha1sum: 186fe3cfbd4076ec1a543e8fd7a76ea0758669ac
---

Russell County Building Department 
137 Highland Dr. 
Lebanon, VA  24266 
Phone: 276-889-8012 
 Fax:  276-889-8009 

build@russellcountyva.us 
Josh Stinson– Building Official 

Property Owner Information 

Name: 

Mailing Address: 

City: State: Zip Code: 

911 Address: Phone: Cell: 

Tax Map I.d.# Septic #: Water Source: 

Directions: 

Applicant Information ( If other than Property Owner) 

Name: 

Mailing Address: 

City/State/ Zip: 

Contractor – Business Name: 

State License # Exp. Date Phone: 

Estimated Cost of Construction:  $ 

Please Complete : 

Type of Work # of Tanks Size/ Use 

Installation of Tanks 

Removal of Tanks 

Closure of Tanks 

Lab Analysis/Log Sheet 

I hereby certify that I am the owner of the record of the herein described property, or that the proposed work has 
been authorized by the owner of record and that I have been authorized to make this application as a designated 
agent I agree to conform to all applicable state and local regulations, rules and policies and such shall be deemed a 
condition entering into the exercise of the permit. In addition, if a permit is issued, I certify that the code official or 
his authorized representative shall have the authority to enter the area(s) described herein at any reasonable hour for 
the purpose of enforcing the provisions of the applicable code(s). 

Applicant:      Date: 
 Signature 

FOR COUNTY USE ONLY 

Date Application Received:          Received By: 

Building Permit Fee: $   Total Fee Amount: 

Tank Permit Permit Application

Russell County Building Department
137 Highland Dr.

Lebanon, VA 24266

Phone: 276-889-8012

Fax: 276-889-8009

build@russelleountyva.us
Josh Stinson Building Official

Tank Permit Permit Application

Property Own

formation

Name:

Mailing Address:

City State: Zip Code:
911 Address: Phone: Celt:
‘Tax Map La Septic #: Water Source:

Directions:

Applicant Information (If other than Property Owner)
Name:

Mailing Address:

City/Statel Zip:

Contractor ~ Business Name:

State

ieee [sp Dave [Phones

Estimated Cost of Construction: $

Please Complete

Type of Work # of Tanks Size/ Use

Installation of Tanks

Removal of Tanks

Closure of Tanks

Thereby certify that Iam the owner ofthe record of the herein described property, oF that the proposed work has
‘been authorized by the owner of record and that I have been authorized to make this application asa designated
1d local regulations, rules and policies and such shall be deemed
‘addition, fa permit is issued, I certify thatthe code official or
‘tw enter the area(s) deseribed herein at any reasonable hour for
ble code(s).

the purpose of enforcing the provisions ofthe appl

Applicant: Date:

FOR COUNTY USE ONLY
Date Application Received: Received By:

Building Permit Fee: Total Fee Amount:





Russell County Building Department 
137 Highland Dr. 

Lebanon, VA  24266 
Phone: 276-889-8012 
    Fax:  276-889-8009 

build@russellcountyva.us 
Mickey L. Rhea – Building Official 

 

Russell County Building Department
(137 Highland Dr.
Lebanon, VA 24266
Phone: 276-889-8012
Fax: 276-889-8009
build@russelicountyva.us
Mickey L. Rhea ~ Building Official



	Property Owner Information
	Applicant Information ( If other than Property Owner)
	I hereby certify that I am the owner of the record of the herein described property, or that the proposed work has been authorized by the owner of record and that I have been authorized to make this application as a designated agent I agree to conform to all applicable state and local regulations, rules and policies and such shall be deemed a condition entering into the exercise of the permit. In addition, if a permit is issued, I certify that the code official or his authorized representative shall have the authority to enter the area(s) described herein at any reasonable hour for the purpose of enforcing the provisions of the applicable code(s).
	FOR COUNTY USE ONLY
	Date Application Received:                                                      Received By: 
	Building Permit Fee: $                                                      Total Fee Amount:

	Name: 
	Mailing Address: 
	City: 
	State: 
	Zip Code: 
	911 Address: 
	Phone: 
	Cell: 
	Tax Map Id: 
	Septic: 
	Water Source: 
	DirectionsRow1: 
	DirectionsRow2: 
	DirectionsRow3: 
	Applicant Information  If other than Property Owner: 
	Name_2: 
	Mailing Address_2: 
	CityState Zip: 
	Contractor  Business Name: 
	State License: 
	Exp Date: 
	Phone_2: 
	Estimated Cost of Construction: 
	 of TanksInstallation of Tanks: 
	Size UseInstallation of Tanks: 
	 of TanksRemoval of Tanks: 
	Size UseRemoval of Tanks: 
	 of TanksClosure of Tanks: 
	Size UseClosure of Tanks: 
	 of TanksLab AnalysisLog Sheet: 
	Size UseLab AnalysisLog Sheet: 
	Applicant: 
	Text1: 
	Text2: 
	Text3: 
	Text4: 
	Text5: