Full Text
Water and Wastewater Services Application ☐Sewage System ☐ Water Supply Is this for your Primary Place of Residence ☐YES ☐NO Private Sector Documentation ☐YES ☐NO If no, Petition for Services Form Attached ☐YES ☐NO *Most applications must be accompanied by private sector evaluations and designs. Applicant: Mailing Address:_ _ Phone: Email: Owner: _ Mailing Address: Phone: Email: Site Address or Directions to Property: Parcel Number (PIN): Subdivision Name: Lot: _ TYPE OF STRUCTURE TO BE SERVED BY WATER SUPPLY OR SEPTIC SYSTEM: ☐Residential ☐Non-Residential Structure Description: ☐ Single Family Dwelling ☐ Other SEWAGE SYSTEM: ☐Existing -OR- ☐Proposed / ☐Public -OR- ☐Private System is more than 1000 Gallons Per Day: ☐ Yes ☐ No Proposed Number of Bedrooms: Existing Number of Bedrooms: Proposed Gallons Per Day: Application Type: ☐Septic Permit (New Construction) ☐Minor Modification - Existing System ☐Convert Certification Letter to Permit ☐Voluntary Upgrade ☐Septic Repair ☐Certification Letter ☐Safe Adequate and Proper Evaluation ☐Sewage Treatment Plant WATER SUPPLY SYSTEM: ☐Existing -OR- ☐Proposed / ☐Public -OR- ☐Private Application Type: ☐Private Drinking Well ☐Irrigation/Agricultural Well ☐Heat Pump Well (Geothermal) ☐Well Abandonment ☐Replacement Well (Run Dry) ☐Replacement Well (Drilled Dry) ☐Public Well ☐Well Modification ☐Hydrofrack Well ☐Hydrogeological Test Well ☐Monitoring Well Water System Type: ☐ Individual Well ☐ Communal Well ☐ Other: _ OFFICE USE ONLY: HD ID#: OTHER: Loudoun County Health Department Environmental Health 1 Harrison Street S.E., P.O. Box 7000 Leesburg, VA 20177-7000 (703) 777-0234 www.loud oun.gov/eh ---PAGE BREAK--- Water and Wastewater Services Application I give permission to the Loudoun County Health Department to enter onto the described property during normal business hours for the purpose of processing this application and performing 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 have been constructed and approved: ☐Owner ☐Agent {Affidavit from property owner attached if not owner ☐YES ☐NO} PROPERTY OWNER/AGENT: (Print Name - Required Current Legal Property Owner) SIGNATURE: DATE: ATTACH SUPPORTING DOCUMENTATION, FEE, AND RETURN TO: LOUDOUN COUNTY HEALTH DEPARTMENT P.O. Box 7000 MSC #68 Leesburg, VA 20177-7000 Make Checks Payable to County of Loudoun This form contains personal information subject to disclosure under the Freedom of Information Act. Rev. 3/22/2024 SURVEY PLAT / SITE SKETCH: Survey Plat Attached: ☐YES ☐NO / Site Sketch Attached: ☐YES ☐NO *In order to process your application for a sewage system, a survey plat of the property as well as a site sketch is required. *For water supplies, a site sketch is required (a survey plat of the property is recommended). All Items Below Are REQUIRED To Be Shown on the Site Plan within 200 feet of Property Lines Property lines (proposed and existing) Houses/Buildings/Structures (proposed and existing) Water supplies - All types (proposed and existing) Sewage systems - All types (proposed and existing) Site features (drainage ways, swampy areas, rock outcrops, sinkholes, disturbed soil areas, dump sites, fuel tanks, etc.) Underground utilities (proposed and existing, must be field marked by utility) *The property lines, proposed building locations, and the proposed well and/or sewage sites must be clearly marked on the property prior to the Health Department site evaluation, and the property must be sufficiently visible to see the topography. All Items will be marked and visible: ☐YES ☐NO DESCRIPTION OF WORK TO BE PERFORMED: (Must provide a brief description.) Loudoun County Health Department Environmental Health 1 Harrison Street S.E., P.O. Box 7000 Leesburg, VA 20177-7000 (703) 777-0234 www.loudoun.gov/eh SIGN