{"id":2753,"date":"2016-09-28T15:44:25","date_gmt":"2016-09-28T15:44:25","guid":{"rendered":"https:\/\/www.vdh.virginia.gov\/environmental-health\/?page_id=2753"},"modified":"2025-02-04T14:25:51","modified_gmt":"2025-02-04T19:25:51","slug":"onsite-sewage-forms","status":"publish","type":"page","link":"https:\/\/www.vdh.virginia.gov\/environmental-health\/onsite-sewage-water-services-updated\/have-you-considered-using-the-private-sector\/onsite-sewage-forms\/","title":{"rendered":"Onsite Sewage Forms and Application Fees"},"content":{"rendered":"<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>On this page you will find the forms, guidance documents, and fee information\u00a0needed to file an application for an onsite sewage system and\/or private well.<\/p>\n<p><a href=\"https:\/\/www.vdh.virginia.gov\/environmental-health\/onsite-sewage-water-services-updated\/septic-system-and-private-well-service-providers\/\">OBTAINING PRIVATE SECTOR SERVICES<\/a><\/p>\n<p>&nbsp;<\/p>\n<ul>\n<li><\/li>\n<\/ul>\n<table style=\"height: 2048px;\" border=\"1\" width=\"699\" cellspacing=\"0\" cellpadding=\"0\" align=\"center\">\n<tbody>\n<tr class=\"HealthTopics_Header\">\n<td width=\"19%\">\n<p align=\"center\"><strong>VAC Code <\/strong><\/p>\n<\/td>\n<td style=\"width: 23%; height: 5%;\" width=\"23%\">\n<p align=\"center\"><strong>Regulation<\/strong><\/p>\n<\/td>\n<td width=\"56%\">\n<p align=\"center\"><strong>Applicable Forms<\/strong><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 19%; text-align: center;\" valign=\"top\" width=\"19%\">&nbsp;<\/p>\n<p><a href=\"https:\/\/law.lis.virginia.gov\/admincode\/title12\/agency5\/chapter570\/\">12 VAC 5-570<\/a><\/td>\n<td style=\"width: 23%; height: 5%; text-align: center;\" valign=\"top\" width=\"23%\">&nbsp;<\/p>\n<p>Sanitary Regulations for Marinas and Boat Moorings<\/td>\n<td valign=\"top\" width=\"56%\">\n<ul>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/20\/2016\/09\/alt-pumpout-fill-form.pdf\">Alternate Pump-Out Agreement<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/20\/2016\/09\/Marina-Building-Permit-Application2016-V1FINAL.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Application for Construction or Expansion of Sanitary and Sewerage Facilities at Marinas and Other Places Where Boats are Moored<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/20\/2016\/09\/CVA-application-2016.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">CVA Application<\/a><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"text-align: center;\" valign=\"top\" width=\"19%\"><a href=\"https:\/\/law.lis.virginia.gov\/admincode\/title12\/agency5\/chapter610\/\">12 VAC 5-610<\/a><\/td>\n<td style=\"width: 23%; height: 1%; text-align: center;\" valign=\"top\" width=\"23%\">Sewage Handling and Disposal Regulations<\/td>\n<td style=\"width: 56%; height: 5%;\" valign=\"top\" width=\"56%\">\n<ul type=\"disc\">\n<li>See <a href=\"https:\/\/www.vdh.virginia.gov\/environmental-health\/gmp-2015-01-forms\/\">GMP 2017-01<\/a> for Forms 1-14<\/li>\n<li>Form 1: Application for a Sewage Disposal System andor Private Well Construction Permit<\/li>\n<li>Form 2: Cover Page<\/li>\n<li>Form 3: OSE\/PE inspection form<\/li>\n<li>Form 4: Example request for subdivision review<\/li>\n<li>Form 5: Request for professional courtesy review<\/li>\n<li>Form 6:\u00a0Site and soil evaluation report<\/li>\n<li>Form 7: Construction drawing page<\/li>\n<li>Form 8: System specifications worksheet<\/li>\n<li>Form 9: Private well worksheet<\/li>\n<li>Form 10: Private well abandonment worksheet<\/li>\n<li>Form 11: Request for Survey Waiver<\/li>\n<li>Form 12: Verification of Sewage System Location<\/li>\n<li>Form 13: Refund Affidavit<\/li>\n<li>Form 14: Malfunction Assessment<\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/20\/2016\/05\/BWE23-1.pdf\">Application for Sewage Handling Permit<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/20\/2016\/05\/PumpHaul.pdf\">Application for Pump and Haul Storage Facility Construction Permit<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/20\/2016\/05\/Appendix-F.pdf\">Field Guide to Soil Textures (Appendix F)<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/20\/2016\/05\/Appendix-G.pdf\">Percolation Test Procedure (Appendix G)<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/20\/2016\/05\/Perc-test.pdf\">Soils Evaluation Percolation Test Data<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/20\/2019\/09\/Completion-Statement-9-19-19.pdf\">Completion Statement<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/20\/2020\/05\/Request-for-Health-Department-Review-SAP.pdf\">GMP 2017-03 Appendix 2b Request for Health Department Review<\/a><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"text-align: center;\" valign=\"top\" width=\"19%\">&nbsp;<\/p>\n<p><a href=\"https:\/\/law.lis.virginia.gov\/admincode\/title12\/agency5\/chapter613\/\">12 VAC 5-613<\/a><\/td>\n<td style=\"width: 23%; height: 5%; text-align: center;\" valign=\"top\" width=\"23%\">Regulations for Alternative Onsite Sewage Systems<\/td>\n<td valign=\"top\" width=\"56%\">\n<ul>\n<li>See forms for 12 VAC 5-610<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"text-align: center;\" valign=\"top\" width=\"19%\">&nbsp;<\/p>\n<p><a href=\"https:\/\/law.lis.virginia.gov\/admincode\/title12\/agency5\/chapter620\/\">12 VAC 5-620<\/a><\/td>\n<td style=\"text-align: center;\" valign=\"top\" width=\"23%\">Regulations Governing Application Fees for Onsite Sewage\u00a0Systems and Private Wells<\/td>\n<td style=\"width: 56%; height: 5%;\" valign=\"top\" width=\"56%\">\n<ul type=\"disc\">\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/environmental-health\/onsite-sewage-and-well-fee-information\/\">Onsite Sewage and Well Fee Information<\/a><\/li>\n<\/ul>\n<div align=\"center\"><\/div>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"text-align: center;\" valign=\"top\" width=\"19%\">&nbsp;<\/p>\n<p><a href=\"https:\/\/law.lis.virginia.gov\/admincode\/title12\/agency5\/chapter630\/\">12 VAC 5-630<\/a><\/td>\n<td style=\"width: 23%; height: 5%; text-align: center;\" valign=\"top\" width=\"23%\">&nbsp;<\/p>\n<p>Private Well Regulations<\/td>\n<td valign=\"top\" width=\"56%\">\n<ul type=\"disc\">\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/20\/2025\/02\/Septic-and-Well-Application-11-11-24-1.pdf\">Application for a Sewage Disposal System and Private\u00a0Well \u00a0Construction Permit<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/20\/2016\/09\/Application-Express-Class-IV.pdf\">Application for an Express Class IV Well Construction Permit<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/20\/2016\/09\/GW-2_UniformWaterWellCompletionReportFINALfillable_081916.pdf\">GW-2 Uniform Well Completion Report<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/20\/2016\/09\/GW-2-GW-5-guidance-document_080416.pdf\">Guidance on Completing Uniform Well Completion Report<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/20\/2016\/09\/GW-5-Well-Abandonment-Form-fillable_080416.pdf\">GW-5 Well Abandonment Form<\/a><\/li>\n<li>Form 2W: <a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/20\/2018\/07\/Well-Permit-Application-Cover-Page-Final-6.21.2018.pdf\">Well Only Cover Page<\/a><\/li>\n<li>Form 7W: <a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/20\/2018\/07\/Well-Permit-Application-Construction-Drawing.pdf\">Well Only Construction Drawing Page<\/a><\/li>\n<li>Form 9: <a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/20\/2016\/05\/Well-Specifications.pdf\">Private Well Worksheet<\/a><\/li>\n<li>Form 10: <a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/20\/2016\/05\/Well-Abandonment-Specifications.pdf\">Private Well Abandonment Worksheet<\/a><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"text-align: center;\" valign=\"top\" width=\"19%\">12 VAC5-635<\/td>\n<td style=\"width: 23%; height: 5%; text-align: center;\" valign=\"top\" width=\"23%\">Rainwater Harvesting System Regulations<\/td>\n<td valign=\"top\" width=\"56%\">\n<ul>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/20\/2024\/10\/Rainwater-Harvesting-System-Application-FINAL.pdf\">Application for a Tier 4 Rainwater Harvesting System Construction Permit<\/a><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"text-align: center;\" valign=\"top\" width=\"19%\">&nbsp;<\/p>\n<p><a href=\"https:\/\/law.lis.virginia.gov\/admincode\/title12\/agency5\/chapter640\/\">12 VAC 5-640<\/a><\/td>\n<td style=\"width: 23%; height: 5%; text-align: center;\" valign=\"top\" width=\"23%\">Alternative Discharging Sewage Treatment Regulations for Individual Single Family Dwellings<\/td>\n<td valign=\"top\" width=\"56%\">\n<ul type=\"disc\">\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/20\/2018\/08\/COMBINED-APPLICATION-04-28-2014-fillable.pdf\">COMBINED APPLICATION 04 28 2014 fillable<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/20\/2018\/08\/COMPLETION-STATEMENT-04-28-2014-fillable.pdf\">COMPLETION STATEMENT 04 28 2014 fillable<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/20\/2018\/08\/PERMIT-TRANSFER-UNDER-220-E-02-02-2016-fillable.pdf\">PERMIT TRANSFER UNDER 220 E 02 02 2016 fillable<\/a><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"text-align: center;\" valign=\"top\" width=\"19%\"><a href=\"https:\/\/law.lis.virginia.gov\/admincode\/title12\/agency5\/chapter650\/\">12 VAC 5-650<\/a><\/td>\n<td style=\"width: 23%; height: 5%; text-align: center;\" valign=\"top\" width=\"23%\">Schedule of Civil Penalties<\/td>\n<td valign=\"top\" width=\"56%\">\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 No forms at this time<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h3>ONSITE SEWAGE APPLICATION FEES (Effective July 1, 2019)<\/h3>\n<table border=\"1\" width=\"100%\" cellpadding=\"5\">\n<tbody>\n<tr class=\"HealthTopics_Header\">\n<td><strong>Application Type\u00a0<\/strong><\/td>\n<td><strong>Fee\u00a0<\/strong><\/td>\n<\/tr>\n<tr>\n<td>Certification letter with OSE\/PE documentation, &lt;1,ooo gpd<\/td>\n<td align=\"right\">$320<\/td>\n<\/tr>\n<tr>\n<td><\/td>\n<td align=\"right\"><\/td>\n<\/tr>\n<tr>\n<td>Certification letter with OSE\/PE documentation, &gt;1,000 gpd<\/td>\n<td align=\"right\">$1,400<\/td>\n<\/tr>\n<tr>\n<td>Construction permit for onsite sewage system only, no OSE\/PE documentation<\/td>\n<td align=\"right\">$425<\/td>\n<\/tr>\n<tr>\n<td>Combined well and onsite system construction permit, no OSE\/PE documentation,<\/td>\n<td align=\"right\">$725<\/td>\n<\/tr>\n<tr>\n<td>Combined well and onsite system construction permit with\u00a0OSE\/PE documentation, &lt;1,000 gpd<\/td>\n<td align=\"right\">$525<\/td>\n<\/tr>\n<tr>\n<td>Construction permit for only onsite sewage with OSE\/PE documentation, <span style=\"text-decoration: underline;\">&lt;<\/span>1,000 gpd<\/td>\n<td align=\"right\">$225<\/td>\n<\/tr>\n<tr>\n<td>Construction permit for only onsite sewage with OSE\/PE documentation, &gt;1,000 gpd<\/td>\n<td align=\"right\">$1,400<\/td>\n<\/tr>\n<tr>\n<td>Combined well and onsite system construction permit with OSE\/PE documentation,\u00a0\u00a0&gt; 1,000 gpd<\/td>\n<td align=\"right\">$1,700<\/td>\n<\/tr>\n<tr>\n<td>Private well construction or abandonment permit, with or without OSE\/PE documentation<\/td>\n<td align=\"right\">$300<\/td>\n<\/tr>\n<tr>\n<td>Closed-loop geothermal well system (one fee per well system)<\/td>\n<td align=\"right\">$300<\/td>\n<\/tr>\n<tr>\n<td>Alternative discharge system inspection fee<\/td>\n<td align=\"right\">$75<\/td>\n<\/tr>\n<tr>\n<td>Minor modification to an existing system<\/td>\n<td align=\"right\">$100<\/td>\n<\/tr>\n<tr>\n<td>Appeal before the Review Board<\/td>\n<td align=\"right\">$135<\/td>\n<\/tr>\n<tr>\n<td><strong>New Fee Effective 7\/1\/19: Repair permit for a treatment works, <u>&lt;<\/u> 1,000 gpd without OSE\/PE documentation<\/strong><\/td>\n<td align=\"right\">$425<\/td>\n<\/tr>\n<tr>\n<td><strong> New Fee Effective 7\/1\/19: Repair permit for a treatment works, <u>&lt;<\/u> 1,000 gpd with OSE\/PE documentation<\/strong><\/td>\n<td align=\"right\">$225<\/td>\n<\/tr>\n<tr>\n<td><strong> New Fee Effective 7\/1\/19: Repair permit for a treatment works, &gt; 1,000 gpd with OSE\/PE documentation<\/strong><\/td>\n<td align=\"right\">$1,400<\/td>\n<\/tr>\n<tr>\n<td><strong> New Fee Effective 7\/1\/19: Voluntary upgrade for a treatment works, <u>&lt;<\/u> 1,000 gpd with OSE\/PE documentation<\/strong><\/td>\n<td align=\"right\">$225<\/td>\n<\/tr>\n<tr>\n<td><strong> New Fee Effective 7\/1\/19: Voluntary upgrade for a treatment works, &gt; 1,000 gpd with OSE \/PE documentation<\/strong><\/td>\n<td align=\"right\">$1,400<\/td>\n<\/tr>\n<tr>\n<td><strong> New Fee Effective 7\/1\/19: Safe, adequate, and proper evaluation without OSE\/PE\/Installer\/Operator documentation<\/strong><\/td>\n<td align=\"right\">$150<\/td>\n<\/tr>\n<tr>\n<td><strong> New Fee Effective 7\/1\/19: Safe, adequate, and proper evaluation with OSE\/PE\/Installer\/Operator documentation<\/strong><\/td>\n<td align=\"right\">$100<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>Beginning July 11, 2019, applicants seeking evaluation and design services from VDH must submitted a petition for VDH Services and meet means testing criteria or the VDH Hardship Guidelines.<\/p>\n<p>Applicants whose family income falls below the Federal Poverty Guidelines are\u00a0eligible for a fee waiver. Applicants for onsite sewage system repairs or voluntary upgrades whose family income falls below 200% of the Federal Poverty Guidelines will be eligible for a fee waiver.<\/p>\n<p>Contact your local health department for more information about fees.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>&nbsp; &nbsp; On this page you will find the forms, guidance documents, and fee information\u00a0needed to file an application for an onsite sewage system and\/or private well. OBTAINING PRIVATE SECTOR SERVICES &nbsp; VAC Code Regulation Applicable Forms &nbsp; 12 VAC 5-570 &nbsp; Sanitary Regulations for Marinas and Boat Moorings Alternate Pump-Out Agreement Application for Construction [&hellip;]<\/p>\n","protected":false},"author":172,"featured_media":0,"parent":470,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_lmt_disableupdate":"no","_lmt_disable":"","footnotes":""},"tags":[],"class_list":["post-2753","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Onsite Sewage Forms and Application Fees - Environmental Health<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.vdh.virginia.gov\/environmental-health\/onsite-sewage-water-services-updated\/have-you-considered-using-the-private-sector\/onsite-sewage-forms\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Onsite Sewage Forms and Application Fees - Environmental Health\" \/>\n<meta property=\"og:description\" content=\"&nbsp; &nbsp; On this page you will find the forms, guidance documents, and fee information\u00a0needed to file an application for an onsite sewage system and\/or private well. 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