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Licensed & Insured • VA 2705163102

Serving Central Virginia Since 2005

24/7 Emergency Service

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Drainfield Repair / Replacement Form

This information will help our team evaluate your septic system concerns and determine the appropriate next steps for drainfield repair or replacement on your property.

"*" indicates required fields

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This field is for validation purposes and should be left unchanged.

1. Customer Contact Information

Name*

Email*

Enter Email Confirm Email

Phone*

Preferred Contact Method*

2. Property / Service Information

Service Address*

Street Address Address Line 2 City State ZIP Code

Is this the same as your mailing/billing address?*

Yes

No

Mailing/Billing Address

Street Address Address Line 2 City State ZIP Code

3. Septic System Information

Current System Type (if known)

Conventional

Alternative

Conventional with pump

Unknown

Septic Tank Size (if known)*

1,000 Gallon

1,250 Gallon

1,500 Gallon

Unknown

Other size

Other tank size

Tank Material*

Concrete

Plastic

Metal

Unknown

Number of bedrooms (per permit)*

Approximate year system was installed*

Pumped in the last 3 years?*

Yes

No

Not Sure

Pumping company and date (if known)

4. Drainfield Problem Symptoms

Drainfield Problem Symptoms (check all that apply)*

Sewage backup in house

Slow drains

Gurgling sounds

Standing water over drainfield

Wet or spongy yard

Sewage odor outdoors

Lush green grass over drainfield

Alarm sounding (if applicable)

System completely failed

Other

Other Symptom(s)

5. Timeline & Urgency

When did the problem start?*

Today

This week

Last 30 days

Longer

Is sewage backing up now?*

Yes

No

Are you currently living in the home?*

Yes

No

Any upcoming events requiring urgent repair?*

Yes

No

If yes, explain.

6. Previous Work or Repairs

Has the drainfield ever been repaired?*

Yes

No

Not sure

If yes, what was done?

Any additives or chemicals used?*

Yes

No

Any heavy equipment driven over drainfield?*

Yes

No

7. Property & Site Conditions

Information helps technicians plan equipment

Yard access for equipment:*

Easy

Limited

Tight/Fenced

Terrain:*

Flat

Sloped

Steep

Soil stays wet year-round?*

Yes

No

High water table area?*

Yes

No

Not Sure

Known issues (check all that apply):*

Clay soil

Rock

Tree roots

Sprinkler system present?*

Yes

No

Pets on property?*

Yes

No

Septic tank lid accessible?*

Yes

No

Not Sure

8. Water Use & Household Load

Number of full-time occupants*

Guests or short-term rental use?*

Yes

No

Garbage disposal used regularly?*

Yes

No

Laundry loads per week (approx)*

Large tubs / hot tub?*

Yes

No

9. Permits & Records (Virginia-Helpful)

Do you have a copy of the septic permit?*

Yes

No

Septic Permit (Optional)

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 10 MB.

Has the health department been contacted?*

Yes

No

Are you aware of any reserve drainfield?*

Yes

No

Property in Chesapeake Bay Preservation Area?*

Yes

No

10. Additional Notes & Uploads (Optional but very helpful)

Upload Photos: Wet areas, tank lids, alarms, etc. (Optional)

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 10 MB.

Rough sketch of yard showing house, well, septic, and drainfield

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 10 MB.

Anything else we should know about the property or project? (Optional)

11. Authorization & Acknowledgement

Consent: I give permission to locate tank & lines*

I give permission to locate tank & lines*

Consent: I give permission to contact local health department*

I give permission to contact local health department*

Consent: I acknowledge that inspection may be required before repair*

I acknowledge that inspection may be required before repair*

Signature*

By signing below, you confirm that the information provided is accurate to the best of your knowledge and grant Drainfield Solutions permission to evaluate, locate, and perform diagnostic work related to your septic system. You acknowledge that additional inspections or approvals may be required before repairs or replacement can begin.

Once submitted, our team will review your information and follow up to discuss next steps, scheduling, and any applicable pricing, payments, or requirements.

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Virginia’s trusted septic and drainfield experts since 2005. Professional service, honest pricing, and emergency response available.

(804) 633-1808
17507 Richmond Turnpike
Milford, VA 22514
info@drainfieldsolutions.com

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Richmond, VA
Fredericksburg, VA
Petersburg, VA
Ashland/Hanover, VA
Chester, VA
Midlothian/Bon Air, VA
Colonial Heights, VA

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Sat & Sun: Emergency Only

24/7 Emergency Service Available

Weekend / Evening Emergencies:
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Licensed & Insured • VA 2705163102