Items 1 through 7 to be filled by the Planning Department, Division of Permits & Inspections (P&I):
Permit Holder: I hereby acknowledge the receipt of this form and I fully understand I must return this form to the on-site waste-water owner to comply
with the requirements of this permit.
Permit Holder’s Signature
Items 8 through 11 to be filled out by on-site wastewater systems owner:
Notice: This form is part of your plumbing permit and should be filled out and returned to the following address within 60 days of permit
issuance: Virginia Beach Department of Public Health, Office of Environmental Services, 4452 Corporation Lane, Virginia
Beach, VA 23462. All work must be completed in accordance to the instructions provided below and in compliance with the City Code,
Sections 28-46 through 28-50. Please see language of pertinent section of the Code below. For more information on the City Code and
Administrative Policy No. PU/ENG-1108, please call the Department of Public Utilities during business hours at 427-4171 and ask for the
Engineering Division.
_________________________________ ____________ _________________________________ ____________
Contractor’s Signature Date Owner’s Signature Date
Ite m s 12-16 to be filled out by the Virginia Beach Department of Public Health:
A. Have a licensed hauler pump the liquid, sludge, and scum from all tanks in the system.
B. Disconnect the septic tank from the structure and the drain field.
C. Disconnect power at the source to all electrical controls and remove all controls and panels.
D. Use one of the following methods of abandonment:
a. Physically remove tank from the site and dispose of at a proper waste fill site or
b. Fill the tank with a non-organic material such as sand, gravel or
c. Crush the tank in place and cover to grade.
E. Remove all parts of the drain field on the ground surface such as valves, valve boxes, and risers, back fill the area to a natural
grade and establish a vegetative cover.
F. Coat all surfaces exposed to septic tank effluent with hydrated lime and establish a vegetative cover.
G. Wait at least 24 months before using the disposal area for gardening or construction.
If the form is not returned by the abandonment expiration date (see item 7 above), you will be in violation of City Code and subject to legal
action. Should you have any questions regarding abandonment and enforcement procedures, please call the Virginia Department of Public
Health at 518-2646.
Virginia Beach City Code Section 28-50 Removal, etc., of inoperative septic tanks.
“All inoperative septic tanks must be removed or, in lieu thereof, be pumped out and filled with sand gravel or other similar acceptable
material, unless such septic tank is inspected by a representative of the department of public health and is found to meet the standards of
health and safety established by the director of public health, as approved by city council. (Code 1965, § 17-39)”.
1. Owner: _______________________________________________ 2: Phone #: __________________________________
3. Property Address: _____________________________________________________________________________________
4. GPIN #: __________________ 5. Date of Permit Issued: _________________________
Permit #: __________________ 7. Abandonment Expiration Date: _________________ (60 Days from permit issuance)
8. Check the method of abandonment:
a. Removal b: Fill the tank c. Crush in place
If method of abandonment is 8(b), describe type of material used: _____________________________________________
9. Contractor’s or Homeowner’s Name: ______________________________________________________________________
10. Contractor’s or Homeowner’s Address: _____________________________________________________________________
11. Date of Abandonment: ______________________
12. Health Department ID #: __________________________________ 13. Health Dept. follow-up date: ________________
14. Health Inspector:_________________________________________ 15. Comments: ______________________________
16. Date the form was received from P&I: _____
______________________ ______________________________
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