Form Eho4 - Request For A Routine Water Sample July 2015 printable pdf download

Form Eho4 - Request For A Routine Water Sample July 2015

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C o u n t y o f F a i r f a x , V i r g i n i a

To protect and enrich the quality of life for the people, neighborhoods and diverse communities of Fairfax County

REQUEST FOR A ROUTINE WATER SAMPLE

I, hereby, request that the Fairfax County Health Department obtain a water sample(s) to

determine the potability of the well water for human consumption, and inspect the existing

well water supply at the address shown below to determine its compliance with the local

and state codes related to construction standards. Furthermore, I understand that a repair

permit may be necessary to bring the existing well water supply into compliance with local

codes. If public water is available, the Health Department recommends a connection be

made in lieu of repairs to the well water supplies not meeting the codes and/or regulations.

A minimum of seven days must be allowed for notification of the bacteriological test results.

The fee for a routine water sample is $25. The fee can be paid by cash, check or credit

card. Upon receipt of the application and fee, you will be notified by phone of the test

results.

Mail check and completed application in the enclosed envelope. Please make check

payable to the County of Fairfax.

Note: Fee is non-refundable.

Signature: ___________________________________ Date: ______________________

SUBDIVISION:_________________________ SECTION:___________ LOT: ________

PROPERTY ADDRESS: ___________________________________________________

OWNER/TENANT: ________________________________________________________

MAILING ADDRESS (If different than property): _________________________________

_________________________________

HOME PHONE: ____________________

WORK PHONE: __________________

DEPARTMENT USE ONLY

DATE RECEIVED: _________________________ TAX MAP NO. ___________________

AP# ____________________________

TRANSACTION# _______________________

Fairfax County Health Department

Division of Environmental Health

Onsite Sewage and Water Section

10777 Main Street, Suite 102, Fairfax, VA 22030

Phone: 703-246-2201 TTY: 711 Fax: 703-653-9448

EHO4 REV. 7-15

Form Eho4 - Request For A Routine Water Sample July 2015