Permit/Site Inspection Request Sheet

CMH Sales Center #:		Job Name:
Job Address:		City/St/Zip:
Model Name:		Square Footage:
Home Phone:		Cell/Work Phone:
County:		Permit #:
New or Replacement?		Setup Crew
Well Crew		Septic Crew

GPIN:	Tax Map #	Health Permit #
Power Company:	Inquiry #	Engineer Name:
Engineer Phone #:	Park or Land
Surveyor Name:	Surveyor Phone

Site inspection and septic tank/drain field inspection:
Site and erosion plan if Surveyor is not required.

Soil Analysis for Health Permit
Health Permit: Standard or Health Permit: Alternative AOSE designed

Highway Access Permit $100.00–VDOT – Requires Surety Bond (up to 2000.00). $1.00 per $100.00
DCR Erosion Permit VSMP (Va. Storm Water Management Permit- Required by Chesapeake Bay Act-Fee applies if disturbed land exceeds 1 acre.
DCR Storm Water Pollution Permit SWPPM Storm Water Pollution Prevention Management preparation as required by the General VSMP Permit.
Erosion Surety Bond (may be required during inclement weather conditions)
(Note: Home First can provide this)

Zoning Permit: RLD Permit- Responsible Land Disturber Certificate Holder Required
Building Permit Electrical Permit Plumbing Permit Mechanical Permit Gas Permit

Comments/Notes:

Sales Person Digital Signature
Email Address
Date