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SG-55 West Virginia Department of Health & Human Resources
Rev. 11/11 __ __________________ Health Department
REQUEST FOR HOME LOAN EVALUATION OF WELL AND/OR SEWAGE SYSTEM
TO BE COMPLETED BY THE APPLICANT
Lender:
Mailing Address:
City: State: Zip Code:
Case Number:
County Tax Map:
Parcel Number:
Purchaser:
Property Owner:
Mailing Address:
City: State: Zip Code:
Mailing Address:
City: State: Zip Code:
Phone Number:
Phone Number:
Detailed directions to the property:
Subdivision Name:
Section:
Lot No.:
Multi-living
units
Number of
Bedrooms
Water
Supply
Sewage
Disposal
Dwelling occupied
for last 30 days?
Basement Dwelling
Yes
No
Public
Private*
Public
Private*
Yes
No
Yes
No
New Existing
Year Built
*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: Date Received: Amount Received: From:
Water Supply: Drilled Well Dug Well Cistern Spring Other:
Installed under permit: Yes No Disinfection system: Yes No Type:
Permit Number: Meets minimum physical design requirements: Yes No Cannot be determined
Bacteriological sample collected: Yes No Date inspected / sampled:
Bacteriological sample results: Satisfactory Unsatisfactory Laboratory sample number:
NOTE: Inspection and sampling does not address chemical contamination, mineral concerns, or yield of the supply.
The water supply was found to be: Satisfactory Unsatisfactory as a potable water supply.
Sewage Disposal System: Type:
Sewage system installed under a permit: Yes No 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: Yes No
Date of original inspection: Date dye test conducted: Dye observed: Positive Negative
The design loading of the facility remains within the minimum standards as originally sized: Yes No
The sewage disposal system: Appears to be Functioning Appears to be Not Functioning Could not be
determined satisfactorily at the time of the evaluation.
REMARKS:
Date: Sanitarian: