REQUEST AN EVALUATION

REQUEST FOR AN EVALUATION

Well & Septic
Items marked with a red asterisk * are required!
Loan Type:

Conventional LoanFHA / VA Loan (add $20 if Lead sample is required)
Service Request Date:

MonthDayYear
Conduct After:

MonthDayYear
Before:

MonthDayYear
Closing:*

MonthDayYear
Services Requested:

Well & Septic ($230)Well Only ($180)Septic Only ($170)Resample ($85)Re-check ($70)Bacteria & Nitrate Sampling ($100)Lead Screen Sample ($20)
(**Fees shown apply to Winnebago, Boone, and Whiteside Counties; others: + $35.00 for up to 40 miles, + $2.00/one-way mapped mile for over 40 miles from Alpine $ East State St., Rockford OR Junction of Highway 40 & 2 in Sterling)
County:

BooneWinnebagoOgleWhitesideOther
Contract:*

NWIARMulti. Bd.MREDOther
Property Site Address*
City*
Zip*
House Vacant?*

YesNo
If yes, how long?
Yrs. / Mos.
Last Repair Date

MonthDayYear
(If known)
Well Location
(front / rear / side of)
Septic Location
(front / rear / side of)
Primary Contact:*

OwnerRealtorOther
Contact Regarding:*

ScheduleReportInvoice
Primary Contact Name:*
E-mail*
example@example.com
Phone Number*
Address
C/O, APT, P.O.Box, etc...
City
State
Zip
Additional Contact:

OwnerRealtorOther
Contact Regarding:

ScheduleReportInvoice
Additional Contact Name:
E-mail
example@example.com
Phone Number
Address
C/O, APT, P.O.Box, etc...
City
State
Zip
REVIEW and check off:
Payment: Cash, Check, PayPal, Credit / Debit Cards accepted

OnlineOnsite
Home Access:*

Someone will be onsiteLockbox
Lockbox Code
(if applicable)
Water is available and accessible during the evaluation?*

YesNoUnknown
Well head location is:*

Above groundIn basementIn pitUnknown
Septic Tank content level is accessible without obstruction removal?*

YesNoUnknown
(**Additional fee applies if we must dig / cut branches / clear debris etc. for tank access.)
Special Instructions:
Should be Empty:

REQUEST FOR AN EVALUATION