Zoning Permit Form
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1Lee County
Department of Zoning
P.O. Box 912
Jonesville, VA 24263
Zoning Permit No. ____________________
Tax Map No. ______________________________
Today’s Date: _______________
Permit Expires 1 Year to Date
Name: __________________________________ Address: ________________________________
City: ____________________________________ Phone (
) ____________ Owner Y ___ N ___
* Owner’s name, if different from above _________________________________________________
Address ___________________________________________________Phone_________________
________________________________________________________________________________
Existing Zone ____________ Deed Book ________ Page # ________ Deed Document # ________
This applicant has applied for a permit to:
______ Build new single-family dwelling
______ Build new multi-family dwelling
______ Place a singlewide mobile home
______ Place a doublewide home
______ Replace a singlewide mobile home
______ Replace a doublewide home
______ Other ____________________________________________________________________
Location of Project: ________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Size (in acres) _______________________
Existing Land Use ___________________________
Surrounding Land Uses:
East ____________________________________
West _________________________________
North ___________________________________
South_________________________________
Other Dwelling on Property? _________________________________________________________
If so, relationship to occupants to applicant______________________________________________
Maximum height ___________________________ Minimum Lot Size ________________________
Set Backs: Front ____________________ Rear _________________ Side ___________________
Physical Site Characteristics: _________________________________________________________
Other: ___________________________________________________________________________
The applicant will need the following:
________ Reconnect onto existing system ________ Perc Test to apply for new system
________ City Water ________ Well Water ________ Spring Water
________ City Septic ________ Private Septic
I herby certify that the above information is true and correct to the best of my knowledge. I
understand that misrepresentations my result in the zoning permit being withheld or possible legal
actions taken if the zoning ordinance is knowingly violated.
Signature of Applicants: _____________________________________________________________
________________________________________________________________________________
Approval of Zoning Administrator: _____________________________________________________
Please attach a map showing the site, lot line dimensions, location of any proposed structures and
distances to lot lines from structure(s).
_______ Zoning Permit
________ Perc Test Only
Fee Charged $ __________
Collected as – Check # ___________ Cash __________
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