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2. First Name*
3. Last Name*
5. Mailing Address*
6. Street Address / Physical Address*
8. City*
9. State*
10. Zip*
11. Email Address*
13. Telephone Number*
14. Alternate Telephone
16. When was the last time your septic system was pumped?*

    Please enter month and year if known. Enter UNKNOWN if you don't know the date.

18. Number of People in Household*
20. Household Income*

    Please refer to the chart on our Septic Pump-Out Program page for income eligibility (200% of the Federal Poverty Guidelines for the number of people in your household). Approved applicants may be asked to provide more information to verify their annual household income.

22. Are you renting the property?*

    Select one.

    1. Yes
    2. No
24. If you answered "Yes" to the question above, are you responsible for the maintenance of the property's septic system?

    Optional - select one.

    1. Yes
    2. No
26. Applicant Acknowledgments

    Please acknowledge the information below by checking the box.

    1. 1. I certify that all information provided to the Regional Commission and Roanoke County is true and accurate to the best of my knowledge.
    2. 2. I acknowledge that the Program will only pay for the cost associated with uncovering a septic tank up to $150.
    3. 3. I agree to attend either an in-person or virtual workshop as part of my participation in the program.
    4. 4. I agree to allow the Program staff to take pictures of, video record, or interview me and the work completed on my property as part of the Program marketing/outreach efforts.
Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field