Request for Health Department Review:
To Be Completed By Property Owner or Agent
Home Telephone:Owner Name: __________________________ __________________
Office Telephone:Mailing Address: ________________________ __________________
Cell Phone:__________________________________________ _______________________
Email Address: ________________________________________________________________________
Home Telephone:Agent Name: ____________________________ __________________
Office Telephone:Mailing Address: _________________________ __________________
Cell Phone:___________________________________________ _______________________
Email Address: _________________________________________________________________________
Property Location (Provide Directions for Local Health Department):_____________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
PIN No.:Tax Map No: _________________________ __________________________
Lot No.:Subdivision Name (if applicable): ______________________ ____________________
Current Use (Including No. of Bedrooms: _____________________________________________
Proposed Use (Include No. of Bedrooms): ____________________________________________
Please attach any recent records of onsite system (pump-outs, or Operation and Maintenance Reports).
Has property been occupied during previous 30-day period: ☐ YES ☐ NO
The septic tank and distribution box are uncovered for Inspection: ☐ YES ☐ NO
(date) Components will be uncovered by: _________________________
To prevent potential damage to the system VDH recommends homeowners first contact Miss Utility for marking
any underground utilities. The septic tank and distribution box should be carefully excavated by hand.
Uncovering the septic tank and distribution box would cause an undue hardship ☐ YES ☐NO
If YES, reason for hardship: _____________________________________________________________________
___________________________________________________________________________________________
(Examples of hardship: system is relatively new, recently pumped, accurate records exist, or excavation would
likely damage components.)
Health Department ID No.:Related Building Permit No.: _________________ __________________
PLEASE READ CAREFULLY:
This report is only intended to address the above referenced request and does not address evaluation
procedures for sewage systems being sold through real estate transfers, or systems and water supplies being
reused a part of a subdivision process. This document specifically addresses VDH’s implementation of §32.1-
165 of the Coe of Virginia and is not to be used for any unauthorized use.
The property boundaries and building locations are clearly marked or identified at the property. I give
permission to the Virginia Department of Health to enter the property described, if necessary, for the purpose
of processing this application. An accurate sketch of the property, existing structures, wells, sewage disposal
systems, and proposed structure(s) is attached.
Date:Owner/Agent Signature: ________________________________ _____________________
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