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..
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