{"id":2194,"date":"2025-04-24T13:49:16","date_gmt":"2025-04-24T17:49:16","guid":{"rendered":"https:\/\/www.vdh.virginia.gov\/norfolk\/?page_id=2194"},"modified":"2025-04-24T13:49:16","modified_gmt":"2025-04-24T17:49:16","slug":"sewage-disposal-and-or-water-supply-permit","status":"publish","type":"page","link":"https:\/\/www.vdh.virginia.gov\/norfolk\/sewage-disposal-and-or-water-supply-permit\/","title":{"rendered":"Sewage Disposal and\/or Water Supply Permit"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/norfolk\/wp-json\/wp\/v2\/pages\/2194' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_5_3\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Type of Sewage System:<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_3'><div class='gchoice gchoice_5_3_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.1' type='checkbox'  value='New'  id='choice_5_3_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_3_1' id='label_5_3_1' class='gform-field-label gform-field-label--type-inline'>New<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_3_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.2' type='checkbox'  value='Repair'  id='choice_5_3_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_3_2' id='label_5_3_2' class='gform-field-label gform-field-label--type-inline'>Repair<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_3_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.3' type='checkbox'  value='Expanded'  id='choice_5_3_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_3_3' id='label_5_3_3' class='gform-field-label gform-field-label--type-inline'>Expanded<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_3_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.4' type='checkbox'  value='Conditional'  id='choice_5_3_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_3_4' id='label_5_3_4' class='gform-field-label gform-field-label--type-inline'>Conditional<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_4\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>FHA\/VA<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_4'><div class='gchoice gchoice_5_4_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.1' type='checkbox'  value='Yes'  id='choice_5_4_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_4_1' id='label_5_4_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_4_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.2' type='checkbox'  value='No'  id='choice_5_4_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_4_2' id='label_5_4_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_5\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_5'><span class='gform-field-label__text'>Case Number<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_5_5' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Owner<\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_1'>\n                            \n                            <span id='input_5_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_5_1_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_5_1_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_5_6\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_6'><span class='gform-field-label__text'>Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_5_6' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/div><fieldset id=\"field_5_7\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address<\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_5_7' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_7_1_container' >\n                                        <input type='text' name='input_7.1' id='input_5_7_1' value=''    aria-required='false'    \/>\n                                        <label for='input_5_7_1' id='input_5_7_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_7_2_container' >\n                                        <input type='text' name='input_7.2' id='input_5_7_2' value=''     aria-required='false'   \/>\n                                        <label for='input_5_7_2' id='input_5_7_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_7_3_container' >\n                                    <input type='text' name='input_7.3' id='input_5_7_3' value=''    aria-required='false'    \/>\n                                    <label for='input_5_7_3' id='input_5_7_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_7_4_container' >\n                                        <select name='input_7.4' id='input_5_7_4'     aria-required='false'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' selected='selected'>Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_5_7_4' id='input_5_7_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_7_5_container' >\n                                    <input type='text' name='input_7.5' id='input_5_7_5' value=''    aria-required='false'    \/>\n                                    <label for='input_5_7_5' id='input_5_7_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_7.6' id='input_5_7_6' value='US' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_5_8\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Agent<\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_8'>\n                            \n                            <span id='input_5_8_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_8.3' id='input_5_8_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_8_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_8_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_8.6' id='input_5_8_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_8_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_5_10\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_10'><span class='gform-field-label__text'>Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_5_10' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/div><fieldset id=\"field_5_9\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address<\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_5_9' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_9_1_container' >\n                                        <input type='text' name='input_9.1' id='input_5_9_1' value=''    aria-required='false'    \/>\n                                        <label for='input_5_9_1' id='input_5_9_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_9_2_container' >\n                                        <input type='text' name='input_9.2' id='input_5_9_2' value=''     aria-required='false'   \/>\n                                        <label for='input_5_9_2' id='input_5_9_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_9_3_container' >\n                                    <input type='text' name='input_9.3' id='input_5_9_3' value=''    aria-required='false'    \/>\n                                    <label for='input_5_9_3' id='input_5_9_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_9_4_container' >\n                                        <select name='input_9.4' id='input_5_9_4'     aria-required='false'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' selected='selected'>Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_5_9_4' id='input_5_9_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_9_5_container' >\n                                    <input type='text' name='input_9.5' id='input_5_9_5' value=''    aria-required='false'    \/>\n                                    <label for='input_5_9_5' id='input_5_9_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_9.6' id='input_5_9_6' value='US' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_5_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_11'><span class='gform-field-label__text'>Directions of Property<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_5_11' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_12'><span class='gform-field-label__text'>Subdivision<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_5_12' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_13'><span class='gform-field-label__text'>Section<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_5_13' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_14'><span class='gform-field-label__text'>Block<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_5_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_15'><span class='gform-field-label__text'>Lot<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_5_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_16\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_16'><span class='gform-field-label__text'>Other Property Identifications<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_5_16' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_17'><span class='gform-field-label__text'>Dimension\/size of Lot\/Property<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_5_17' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_38\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Other Application Information<\/h3><\/div><fieldset id=\"field_5_19\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Building\/Facility<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_19'><div class='gchoice gchoice_5_19_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.1' type='checkbox'  value='New'  id='choice_5_19_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_19_1' id='label_5_19_1' class='gform-field-label gform-field-label--type-inline'>New<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_19_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.2' type='checkbox'  value='Existing'  id='choice_5_19_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_19_2' id='label_5_19_2' class='gform-field-label gform-field-label--type-inline'>Existing<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_23\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Intermittent Use<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_23'><div class='gchoice gchoice_5_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Yes'  id='choice_5_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_23_1' id='label_5_23_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='No'  id='choice_5_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_23_2' id='label_5_23_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_23_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.3' type='checkbox'  value='If yes, describe'  id='choice_5_23_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_23_3' id='label_5_23_3' class='gform-field-label gform-field-label--type-inline'>If yes, describe<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_24\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Residential Use<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_24'><div class='gchoice gchoice_5_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='Yes'  id='choice_5_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_1' id='label_5_24_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='No'  id='choice_5_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_2' id='label_5_24_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_25\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Termite Treatment<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_25'><div class='gchoice gchoice_5_25_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.1' type='checkbox'  value='Yes'  id='choice_5_25_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_1' id='label_5_25_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_25_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.2' type='checkbox'  value='No'  id='choice_5_25_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_2' id='label_5_25_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_25_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.3' type='checkbox'  value='Single Family (# of Bedrooms)'  id='choice_5_25_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_3' id='label_5_25_3' class='gform-field-label gform-field-label--type-inline'>Single Family (# of Bedrooms)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_25_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.4' type='checkbox'  value='Multi-family (# of Units)'  id='choice_5_25_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_4' id='label_5_25_4' class='gform-field-label gform-field-label--type-inline'>Multi-family (# of Units)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_26\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Basement<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_26'><div class='gchoice gchoice_5_26_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.1' type='checkbox'  value='Yes'  id='choice_5_26_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_26_1' id='label_5_26_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_26_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.2' type='checkbox'  value='No'  id='choice_5_26_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_26_2' id='label_5_26_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_27\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Fixtures in Basement<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_27'><div class='gchoice gchoice_5_27_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.1' type='checkbox'  value='Yes'  id='choice_5_27_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_27_1' id='label_5_27_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_27_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.2' type='checkbox'  value='No'  id='choice_5_27_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_27_2' id='label_5_27_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_28\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Commercial Use<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_28'><div class='gchoice gchoice_5_28_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.1' type='checkbox'  value='Yes'  id='choice_5_28_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_28_1' id='label_5_28_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_28_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.2' type='checkbox'  value='No'  id='choice_5_28_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_28_2' id='label_5_28_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_28_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.3' type='checkbox'  value='Describe:'  id='choice_5_28_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_28_3' id='label_5_28_3' class='gform-field-label gform-field-label--type-inline'>Describe:<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_35\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_35'><span class='gform-field-label__text'>Describe<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_5_35' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_29\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Commercial\/Wastewater<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_29'><div class='gchoice gchoice_5_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.1' type='checkbox'  value='Yes'  id='choice_5_29_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_29_1' id='label_5_29_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_29_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.2' type='checkbox'  value='No'  id='choice_5_29_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_29_2' id='label_5_29_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_29_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.3' type='checkbox'  value='Number of Patrons'  id='choice_5_29_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_29_3' id='label_5_29_3' class='gform-field-label gform-field-label--type-inline'>Number of Patrons<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_29_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.4' type='checkbox'  value='Number of Employees'  id='choice_5_29_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_29_4' id='label_5_29_4' class='gform-field-label gform-field-label--type-inline'>Number of Employees<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_39\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">If yes, give volumes and describe<\/h3><\/div><fieldset id=\"field_5_33\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Water Supply<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_33'><div class='gchoice gchoice_5_33_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.1' type='checkbox'  value='Public'  id='choice_5_33_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_1' id='label_5_33_1' class='gform-field-label gform-field-label--type-inline'>Public<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_33_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.2' type='checkbox'  value='New'  id='choice_5_33_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_2' id='label_5_33_2' class='gform-field-label gform-field-label--type-inline'>New<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_33_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.3' type='checkbox'  value='Existing'  id='choice_5_33_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_3' id='label_5_33_3' class='gform-field-label gform-field-label--type-inline'>Existing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_33_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.4' type='checkbox'  value='Private'  id='choice_5_33_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_4' id='label_5_33_4' class='gform-field-label gform-field-label--type-inline'>Private<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_33_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.5' type='checkbox'  value='New'  id='choice_5_33_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_5' id='label_5_33_5' class='gform-field-label gform-field-label--type-inline'>New<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_33_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.6' type='checkbox'  value='Existing'  id='choice_5_33_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_6' id='label_5_33_6' class='gform-field-label gform-field-label--type-inline'>Existing<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_34\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_34'><span class='gform-field-label__text'>Describe<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_5_34' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_36\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_36'><span class='gform-field-label__text'>Proposed Sewage Disposal Method:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_5_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_37\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Onsite Sewage Disposal System:<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_37'><div class='gchoice gchoice_5_37_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.1' type='checkbox'  value='Septic Tank Drainfield'  id='choice_5_37_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_1' id='label_5_37_1' class='gform-field-label gform-field-label--type-inline'>Septic Tank Drainfield<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_37_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.2' type='checkbox'  value='LPD'  id='choice_5_37_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_2' id='label_5_37_2' class='gform-field-label gform-field-label--type-inline'>LPD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_37_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.3' type='checkbox'  value='Mound'  id='choice_5_37_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_3' id='label_5_37_3' class='gform-field-label gform-field-label--type-inline'>Mound<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_37_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.4' type='checkbox'  value='Other'  id='choice_5_37_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_4' id='label_5_37_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_41\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_41'><span class='gform-field-label__text'>Attach a site plan (rough sketch) showing dimensions of property, proposed and\/or existing structures and driveways, underground utilities, adjacent soil absorption system, bodies of water, drainage ways, and wells and springs within 200 feet radius of the center of the proposed well or drainfield. Distances may be paced or estimated. The property lines and building location are clearly marked and the property is sufficiently visible to see the topography.<\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='104857600' \/><input name='input_41' id='input_5_41' type='file' class='large' aria-describedby=\"gfield_upload_rules_5_41\" onchange='javascript:gformValidateFileSize( this, 104857600 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_5_41'>Max. file size: 100 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_5_41'><\/div> <\/div><\/div><fieldset id=\"field_5_43\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>The property lines and building location are clearly marked and the property is sufficiently visible to see the topography. I give permission to the department to enter onto the property described for the purpose of processing this application.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_5_43'>\n                            \n                            <span id='input_5_43_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_43.3' id='input_5_43_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_43_3' class='gform-field-label gform-field-label--type-sub '>Name<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_5_44\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_44'><span class='gform-field-label__text'>Date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_5_44'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_44'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_44' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_44' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_44' aria-label='Date: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_5' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Submit<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_5' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_5' id='gform_theme_5' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_5' id='gform_style_settings_5' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_5' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='5' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='pN\/9PUrR3jLhBaroWJSM2g39N4O3u8h7X6ZoPoyNJbihRdYlVmeuIgyokPdI9zWPWxRSbyWanj3S10xK+Nwkpdp+6KkB5L1YzPfqmwPTTA4Grog=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_5' 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