Just fill out this simple form to apply for an Inspection and Reporting Agreement for your onsite wastewater disposal system. After reviewing the application, we may prepare an agreement and mail it to your mailing address. In some cases, we may require a preliminary inspection of your system before executing an agreement. If a preliminary inspection is required, or more information is needed, we will contact you within five (5) business days of receiving this application.

Client Information:
Homeowner Name: Mailing Address: Service Property Address:	Home Phone: Daytime Phone: Other or Email: FAX: Tax Map or GPIN Subdivision/Lot County
System Information:
Type of System: I Don't Know Advantex™ Puraflo® Standard Puraflo® Double Pump Whitewater® Drip Whitewater® Spray Aquarobic™ Filterbed American Drip Conventional Conventional with Whitewater® ATU Conventional with Pump Conventional with Whitewater® ATU and Pump Discharge Not Listed Serial #: Age of System (in years):
Agreement Information:
Are you a new client? Yes No What level of service would you like?** Septi-Check™ Septi-Safe™ Septi-Sure™ How long do you want the contract term to be?** Three Years Two Years Three Years Is the initial term being paid by the homeowner or a third party?** Homeowner Third Party If so, how long? Not Paid By Third Party One Year Two Years Three Years
Additional Services
Do you desire, or does your local health district require any of the following additional services? Biological/Biochemical Oxygen Demand (BOD5) Sample Analysis Yes No Total Suspended Solids (TSS) Sample Analysis Yes No Oils and Grease Sample Analysis Yes No Well Water Sampling Services Water-Check™ Water-Sure™ No Well Services Septi-Chlor™ Yes No
Payment Information:
Please provide billing information below: Bill To: Billing Address:
Terms of Application:
All of the information provided in the "Client Information" section of this form must pertain to the homeowner. Onsite Solutions' agreements are non-transferable, and must be contracted with the owner of the property. Please do not enter builder or installer information in the "Client Information" section of this form. If you indicated that the contract term will be paid by a third party, you are required to fill in the billing information above. Septi-Safe™ and Septi-Sure™ are only available for properties within Prince William, Loudoun, and Fairfax Counties. Please do not select these levels of service if your property is outside of those counties. Our standard contract term is two years. However, all Advantex™ agreements require a three-year contract term. In addition, all Septi-Safe™ and Septi-Sure™ agreements will be automatically assigned a three-year contract term. If the service property is within Loudoun County, we may require the Loudoun County Sampling Options. If the service property is within Fairfax County, we may require the Fairfax County Sampling Options. If the system is a Whitewater® Spray Irrigation System, you are not required to select either the Fairfax or Loudoun Sampling Requirements, because those sampling requirements are already included in Spray agreements (required by the state for Spray systems). You may only select the Septi-Chlor™ attachment if you have a Whitewater® Spray system or a discharge system.
Agreement Confirmation:
Applicant's Name: has read and understands the terms of this application By submitting this form, you acknowledge that you have read the terms of this application, and you agree to abide by them. Furthermore, if you indicated that this agreement is being paid by an entity other than the homeowner, you are acknowledging that that third party is aware of the charges that will be billed to them, and you agree to ensure Onsite Solutions is paid in a timely manner. If you wisht to submit this form, please type your name in the box above, and check the box below, acknowledging that you have read, and you agree to these terms.