Commonwealth of Virginia
Application for Subdivision Review
(page 1 of 2 to be filled out by Owner or Agent)
Owner Phone
Mailing Address Phone
Developer/Agent Phone
Mailing Address Phone
AOSE Phone
Mailing Address Phone
Directions to Property:
Name of Proposed Subdivision
Tax Map Other Property Identification Dimension/Acreage of Property
Number of lots proposed Proposed water source (note: new or existing, public or individual)
General size of lots (give range if appropriate)
Additional description of subdivision
Overview of soils and geology (optional but encouraged)
In order for VDH to process a subdivision application you must attach a plat of the property showing the location of the proposed
onsite sewage disposal systems and the reserve absorption areas (if required) and the location of the water supply system on each
lot, if applicable. Each plate or subsection of a subdivision plat shall be accompanied by specific soil information for each lot
(absorption area and reserve area). If not provided by the local subdivision ordinance, the district or local health department may
require the plat to show streets, utilities, storm drainage, water supplies, easements, lot lines and original topographic contour lines
by detail survey or other information as required.
When the OSE site evaluations are reviewed, the property lines, building location and the proposed well and sewage system sites
must be clearly marked and the property sufficiently visible to see the topography, otherwise this application will be denied.
I give permission to the Virginia Department of Health (VDH) to enter onto the property described during normal business hours for
the purpose of processing the application and to perform quality assurance checks of evaluations and designs certified by an
Onsite Soil Evaluator (OSE) or a Professional Engineer (PE) as necessary until the sewage disposal system has been
constructed and approved.
Signature of Owner/Agent Date
This form contains personal information subject to disclosure under the Freedom of Information Act Revised 9/25/2014
VDH Use Only
Health Department ID# ____________________
Due Date________________________________
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