Homeloan Evaluation Application Inspection of an existing well or septic system for home sale. Step 1 of 3 33% Request for:* Home Loan - Well & Sewage Inspection ($200.00) Home Loan - Sewage Inspection Only ($125.00) Home Loan - Well Inspection Only ($150.00) Type* Duplex Business Single Family Dwelling Lead Test Yes ($30) No Owner's Name* Owner's Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Owner's Phone #*Phone # MAIL PERMIT TO (NAME): MAIL PERMIT TO (ADDRESS): Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Fax #Contact Person* Contact Person Phone #* Property Address:* Parcel ID# County*CassVan BurenTownshipAlmenaAntwerpArlingtonBangorBloomingdaleCalvinColumbiaCovertDecaturGenevaHamiltonHartfordHowardJeffersonKeelerLa GrangeLawrenceMarcellusMasonMiltonNewbergOntwaPaw PawPennPine GrovePokagonPorterPorter (N)Porter (S)Silver CreekSouth HavenVolinaWaverlyWayneSection: Subdivision: Lot #: ACKNOWLEDGEMENT: This survey is provided as a service to residents of Van Buren or Cass County. It is not intended as either an approval or disapproval of the well or the sewage disposal system. The information provided is based upon skilled observations by trained Environmental Health personnel, and is indicative only of the conditions present at the time of the survey. No attempt to draw conclusions has been made. It is expected that the lending institution shall make all appropriate decisions as to suitability. Records relating to the property surveyed are available upon request. Since many factors contribute to the functioning of a water supply or sewage disposal system, any change in circumstances may affect its continued function: I ACKNOWLEDGE AND AGREE that Van Buren or Cass County, its departments, Boards, officers, agents and employees, including without limitations, the Van Buren County or the Cass County Health Department, are not responsible for any loss al legedly due to any act or omission in connection with the performance of the survey or surveys requested herein: Applicant’s Signature :* By typing your own name above you are voluntarily signing this document electronically, acknowledging and agreeing to its terms. Date: Seller's Signature: By typing your own name above you are voluntarily signing this document electronically, acknowledging and agreeing to its terms. Date: Purchaser's Signature: By typing your own name above you are voluntarily signing this document electronically, acknowledging and agreeing to its terms. Date NameThis field is for validation purposes and should be left unchanged.
