SG-55
Rev. 11/11
West Virginia Department of Health & Human Resources
__
__________________ Health Department
REQUEST FOR HOME LOAN EVALUATION OF WELL AND/OR SEWAGE SYSTEM
TO BE COMPLETED BY THE APPLICANT
Lender:
Mailing Address:
City:
State:
Case Number:
County Tax Map:
Parcel Number:
Zip Code:
Purchaser:
Property Owner:
Mailing Address:
City:
State:
Mailing Address:
City:
State:
Zip Code:
Phone Number:
Zip Code:
Phone Number:
Detailed directions to the property:
Subdivision Name:
Multi-living
units
Section:
Number of
Bedrooms
Lot No.:
Dwelling occupied
for last 30 days?
Water
Supply
Sewage
Disposal
Yes
Public
Public
Yes
Yes
New
No
Private*
Private*
No
No
Year Built
Basement
Dwelling
Existing
*If private well, permit number:
, and approximate date well was drilled:
septic system, permit number:
, and approximate date system was installed:
TO BE COMPLETED BY THE HEALTH DEPARTMENT SANITARIAN
Loan Number:
Water Supply:
Date Received:
Drilled Well
Installed under permit:
Permit Number:
Yes
Dug Well
No
Cistern
Disinfection system:
Bacteriological sample results:
Yes
No
Satisfactory
From:
Spring
Other:
Yes
No Type:
Meets minimum physical design requirements:
Bacteriological sample collected:
NOTE:
Amount Received:
Yes
No
Cannot be determined
Date inspected / sampled:
Unsatisfactory
Laboratory sample number:
Inspection and sampling does not address chemical contamination, mineral concerns, or yield of the supply.
The water supply was found to be:
Satisfactory
Sewage Disposal System: Type:
Sewage system installed under a permit:
Yes
No
Unsatisfactory as a potable water supply.
Permit Number:
For surface discharge systems permitted since January 1, 1999, is the WVDEP Registration current:
Yes
No
Note: system cannot be approved without a current registration. Registration cannot be transferred to new owner. New owner must register with
West Virginia Department of Environmental Protection (WVDEP).
System met the minimum design standards at the time of installation:
Date of original inspection:
Date dye test conducted:
Yes
No
Dye observed:
Positive
The design loading of the facility remains within the minimum standards as originally sized:
The sewage disposal system:
Appears to be Functioning
No
Appears to be Not Functioning
determined satisfactorily at the time of the evaluation.
REMARKS:
Date:
Yes
Negative
Sanitarian:
Could not be