Lot 5 AOSE Well Application Quarter Branch_v1

This form contains personal information subject to disclosure under the Freedom of Information Act. Revised 7/1/2019 Commonwealth of Virginia Application for: Sewage System Water Supply Owner __________________________________________________________ Mailing Address __________________________________________________ ________________________________________________________________ Agent _____________________________________________ ______________ Mailing Address __________________________________________________ ________________________________________________________________ Phone _______________________ Phone _______________________ Email_______________________ Phone _______________________ Phone _______________________ Fax _________________________ Site Address _____________________________________________________ ________________________________________________________________ Email _______________________ Directions to Property: _________________________________________________________________________________ Subdivision _______________________________________ Section ______________ Block ________ Lot ___________ Tax Map ____________________ Other Property Identification _______________ Dimension/Acreage of Property _______ Sewage System Type of Approval: Applicants for new construction are advised to apply for a certification letter to determine if land is suitable for a sewage system and to apply for a construction permit (valid for 18 months) only when ready to build. Certification Letter Construction Permit Voluntary Upgrade Repair Permit Minor Modification Proposed Use: Single Family Home (Number of Bedrooms ____ ) Multi-Family Dwelling (Total Number of Bedrooms ____) Other (describe) __________________________________________________________________________________ Basement? Yes No Walk-out Basement? Yes No Fixtures in Basement Yes No Conditional permit desired? Yes No If yes, which conditions do you want? Reduced water flow Limited Occupancy Intermittent or seasonal use Temporary use not to exceed 1 year Do you wish to apply for a betterment loan eligibility letter? Yes No *There is a $50 fee for determination of eligibility. Water Supply Will the water supply be Public or Private? Is the water supply Existing or Proposed? If proposed, is this a replacement well? Yes No If yes, will the old well be abandoned? Yes No Will any buildings within 50’ of the proposed well be termite treated? Yes No Well Type (e.g. domestic use, agricultural, irrigation, etc.) __________________________________________________ All Applicants Is this property intended to serve as your (owners) principal place of residence? Yes No All applications must be accompanied by private sector evaluations and designs, unless a petition for VDH services is approved. Is a Petition for Service form attached? Yes No In order for VDH to process your application for a sewage system you must attached a plat of the property and a site sketch. For water supplies, a plat of the property is recommended and a site sketch is required. The site sketch should show your property lines, actual and/or proposed buildings and the desired location of your well and/or sewage system. When the site evaluation is conducted the property lines, building location and the proposed well and sewage sites must be clearly marked and the property sufficiently visible to see the topography. I give permission to the Virginia Department of Health to enter onto the property described during normal business hours for the purpose of processing this application and to perform quality assurance checks of evaluations and designs certified by a private sector Onsite Soil Evaluator or Professional Engineer as necessary until the sewage disposal system and/or private water supply has been constructed and approved. __________________________________________________ ____________________________________ Signature of Owner/ Agent Date VDH Use only Health Department ID# _____________ Due Date _________________________ Christopher Froemel