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Russell County Building Department
137 Highland Dr.
Lebanon, VA  24266
Phone: 276-889-8012
Fax:  276-889-8009
[email protected]
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
[email protected]
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
[email protected]
Mickey L. Rhea – Building Official
Russell County Building Department
(137 Highland Dr.
Lebanon, VA 24266
Phone: 276-889-8012
Fax: 276-889-8009
[email protected]
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: