nm3clol-public/Russell_County/Building_Department/RC Tank Permit Application Form_202211020903439653

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