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Rev. 2/7/2025 WATER & SEWER APPLICATION Department use only Request Fee ( ) For Evaluation of existing water and/or sewage disposal systems Rec'd by Date PIN # Tax NOTE: Make checks payable to: County of Loudoun Property City: Directions to property from Leesburg: Reason for Water and Sewer Evaluation/ Related Application 1. Current number of bedrooms or capacity: 2. Approximate age of septic system: 3. How many structures are connected to the sewage disposal system? 4. List the structures: The following information is to be provided by the owner of the property. Use back of page if necessary and or attach additional information if needed. Please type or print clearly. Owner: Phone: □ □ Address: Evaluation Requested by: Phone: □ □ Email: Sewage Disposal GIS# (PSSD) Well Water GIS# (WWIN) ---PAGE BREAK--- Page 2 of 3 5. Is there an automatic clothes washer? □Yes □ No a. Is there a garbage disposal installed? □Yes □ No 6. Has the structure/dwelling been occupied under usual and customary waste load conditions for the past 30 days? □ Yes □ No a. By how many people? 7. Describe any history of a malfunction of the sewage disposal system (i.e. backup, pump malfunction, etc.) 8. Do you have a service contract, maintenance contract, or relationship with an operator in place for the sewage disposal system? □ Yes □ No a. Name of Licensed Operator Contract: b. Contract Expiration Date: 9. Date sewage disposal system was last pumped, inspected or serviced: a. Service Provider: b. Describe Service: 10. What is the availability of and distance to public sewer? 11. How many structures are connected to the well/water system? a. List the structures. 12. Describe any history of well problems (insufficient water, muddy water, etc.) 13. List any well water treatment systems: 14. What is the availability of and distance to public water? I CERTIFY THE INFORMATION ON THIS FORM IS CORRECT TO THE BEST OF MY KNOWLEDGE AND GRANT PERMISSION TO THE LOUDOUN COUNTY HEALTH DEPARTMENT TO ACCESS THE PROPERTY: OWNER SIGNATURE: PRINT NAME: ---PAGE BREAK--- Page 3 of 3 Department use only Health Department Application Date INFORMATION YOU SHOULD KNOW ABOUT LOUDOUN COUNTY HEALTH DEPARTMENT WATER AND SEWER EVALUATIONS The Loudoun County Health Department does not accept Evaluation Applications for real estate transactions and other functions that are not County regulated. The Health Department will conduct water and sewer evaluations for various County regulated functions such as existing structures involved in proposed subdivision and structures proposed for changes of use. These functions should have a related “Application Number”, usually a Building and Development or Zoning application number. One evaluation application and fee is required for each sewage disposal system involved with the related application. The owner of the system must provide all the pertinent information and sign the application. The septic tank, including inlet and outlet ports, splitter and distribution boxes must be exposed and accessible. If components are not accessible, the evaluation will be inconclusive. The Health Department must have access to the structure and the structure must have electricity and running water. The locations of all conveyance lines, force mains, and soil absorption areas must be easily identifiable and/or clearly marked. If additional information, inspections or repairs are needed, your application may be kept on "Hold" for up to 3 months to allow for corrections. After that time, the application will be labeled as inconclusive and new water and sewer application and fees will be required. If the dwelling is served by a well water supply system, an inspection will be made of the well construction. The well must meet minimum construction standards in order to be sampled. The sample must be collected by our evaluator and analyzed at our laboratory. Having a water system and/or sewage disposal system that is functioning adequately or found to be “Satisfactory” is not a guarantee that the Loudoun County Health Department will recommend approval of the related application. (10) The current application fee should be made payable to County of Loudoun in the sum of $110.00 per application.