2. 
3. Washington County Septic System Grant Replacement Application

5. Complete this application form and submit it with the required documents, or determination and assistance may be delayed.

7. A. Applicant/Owner Information
9. 1. Name:
11. 2. Phone Number:
13. 3. Mailing Address (Street):
15. Mailing Address (City):
16. Mailing Address (ST):
17. Mailing Address (Zip):
19. 4. Email Address:
23. B. Property Information
25. 1. Street Address of Septic System (if different from mailing address, above):
27. Street Address (City):
28. Street Address (ST):
29. Street Address (Zip):
31. 2. County:
33. 3. Parcel ID #:
35. 4. Property Type:

    1. Residential
    2. Commercial
    3. Other
37. 4A. If you checked Commercial, please specify the nature and size of the business:
39. 4B. If you checked Residential, please indicate whether the property is used as

    1. Primary Residence
    2. Seasonal
41. 5. Number of bedrooms at the property:
43. 6. Year septic system was installed:
45. 7. Description of the septic system installed:
49. C. Project Information
51. 1. Describe any problems with your existing system:
53. 1A. If system has a septic tank:
55. a. What is the approximate size (in Gallons)?
57. b. When was the last time it was pumped (Month & Year)
59. c. What was the volume pumped out (in Gallons)?
61. d. Who was the pump contractor?
63. e. Has tank been pumped more than once?

    1. Yes
    2. No
64. How frequently? (How many years between being pumped)
66. 1B. What is septic tank constructed of?

    1. Concrete
    2. Steel
    3. Block Masonry
    4. Plastic
    5. Other
    6. Unknown
68. 1C. Is an "As-Built" drawing of the construction of the septic system available?

    1. Yes
    2. No
70. If yes, attach a copy of the drawing
72. 2. Project Type:

    1. Repair/Rehabilitation
    2. Replacement
    3. Upgrade (e.g., Advanced Nitrogen Removal System)
74. 3. Total Estimated Project Cost: $
76. 4. Name, Address, and Phone Number of Septic System Project Contractor:
78. Street/Mailing Address
80. City:
81. State:
82. Zip:
84. Phone Number:
86. Inspection Report is required with Application Submission*

90. By signing this application form, the undersigned states that all the information contained in this application is true and correct.

92. Signature (Applicant/Owner)
93. Date Signed
    Date Signed
Leave This Blank:


95. Submit

* indicates a required field