Application For An Evaluation Form
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1
2DEPARTMENT USE ONLY
FAIRFAX COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH
DATE RECEIVED: _____________________
ONSITE SEWAGE AND WATER SECTION
TAX MAP NO._________________________
10777 MAIN STREET, SUITE 102
AREA: _______________________________
FAIRFAX, VA 22030
Phone: 703-246-2201 TTY: 711 Fax: 703-653-9448
RECEIPT NO. _________________________
REPORT MAILED: ____________________
APPLICATION
UNCOVER D BOX:
YES
NO
For Evaluation of Existing Well Water and/or Sewage Disposal Systems
UNCOVER TANK:
YES
NO
Please complete application and return with payment to the Health Department. The evaluation fee for
EHS: ________________________________
a private well water supply is $50, for an individual sewage disposal system is $200; combined well and
septic is $250. Payment can be made cash, check, or credit card. All fees are non-refundable.
MISS UTILITY F/U DATE:_____________
SCHEDULED DATE / EHS:
Proposed Settlement Date: _______________________ Transfer?
Refinance?
______________________________________
Property
Address: ____________________________________________ Subdivision __________________ Sec _____________ Lot _____________
Owner : ____________________________________ Phone: (H) __________________ (O) ________________ (C) ___________________
Address: __________________________________________________________________________________________________________
Evaluation Requested by: _____________________ Phone: (H) ___________________ (O) ________________(C) __________________
SEND REPORT TO: _______________________________________________________________________________________________
Address : __________________________________________________________________________________________________________
The following information must be supplied by the property owner.
ATTACH ADDITIONAL SHEET OF PAPER, IF NECESSARY, TO COMPLETE INFORMATION (Please Type or Print Clearly)
Dwelling is connected to: SEPTIC
PUBLIC SEWER
(Answer 1 thru 7 if septic is checked)
Dwelling is connected to: WELL
PUBLIC WATER
OTHER
(Answer 8 & 9 if well or other is checked)
1. Describe any history of malfunction of the sewage disposal system (i.e. backup, pump malfunction, etc.) _______________________
________________________________________________________________________________________________________________
2. Date septic tank last pumped: ___________ 3. Number of bedrooms ___________ 4. Approximate age of septic system __________
5. Is an automatic clothes washer or hookup installed? ______________ 6. Is there a garbage disposal installed? _________________
7. Has the dwelling been occupied under usual and customary waste load conditions for the past 30 days? ________________________
By how many people? _______________
8. Describe any history of well problems (insufficient water, muddy water, etc.) ____________________________________________
9. Describe any form of water treatment (pH control, filters, etc.) _______________________________________________________
I CERTIFY THE INFORMATION ON THIS FORM WAS SUPPLIED BY THE OWNER AND IS CORRECT TO THE BEST OF MY
KNOWLEDGE:
SIGNATURE __________________________________________________ PRINT NAME ___________________________________
OWNER
AGENT
EHO24 REV. 10-14
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