New Hanover County Health Department
Application for
Improvement Permit and/or Authorization to Construct
____ Improvement Permit ____ Authorization to Construct Tax Parcel #______
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENTS PERMIT IS FALSIFIED, CHANGED, OR THE SITE IS ALTERED, THEN THE IMPROVEMENTS PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. The permit is valid for either 60 months or without expiration depending upon documentation submitted. (complete site plan = 60 months; complete plat = without expiration) APPLICANT INFORMATION
______
Applicant Address Home & Work Phone
Email Address: ______
______
Owner Address Home & Work Phone
Email Address: ______
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PROPERTY INFORMATION date originally deeded & recorded ______
______
Street AddressSubdivision Name Section/Phase/Lot#
Directions to Site: ______Lot Size ______
______
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DEVELOPMENT INFORMATIONResidential Specifications
New Single Family ResidenceMaximum number of bedrooms: ______
Relocation/NewMaximum number of occupants______
Expansion of Existing System If expansion: Current number of bedrooms: ______
Repair to Malfunctioning Sewage Disposal SystemWill there be a basement? yes no
Non-Residential Type of StructurePlumbing fixtures in Basement yes no
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Non-Residential Specifications:
Type of business: ______Total Square footage of Building: ______
Maximum number of employees: ______Maximum number of seats: ______
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Water Supply:Are there any existing wells, springs, or existing waterlines on this property? yes no
New well Existing Well Community Well Public Water Spring
______
If applying for Authorization to Construct: Please Indicate Desired System Type(s):
(systems can be ranked in order of your preference)
Accepted Alternative Conventional Innovative Other ______ Any ______
The Applicant shall notify the local health department upon submittal of this application if any of the following apply to the property in question. If the answer to any question is “yes”, applicant must attach supporting documentation.
yes no Does the site contain any jurisdictional wetlands?
yes no Does the site contain any existing wastewater systems?
yes no Is any wastewater going to be generated on the site other than domestic sewage?
yes noIs the site subject to approval by any other public agency?
yes no Are there any easements or right of ways on this property?
I have read this application and certify that the information provided herein is true, complete and correct. Authorized county and state officials are granted right of entry to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am solely responsible for the proper identification and labeling of all property lines and corners and making the site accessible so that a complete site evaluation can be performed.
______
Property owner’s or owner’s legal representative** signature (required) Date
**Must provide documentation to support claim as owner’s legal representative.EHS074 Vert
7-2016
EHS074 Ver7-2016
NEWHANOVERCOUNTY HEALTH DEPARTMENT Environmental Health Services
230 Government CenterDr., Suite140
Wilmington, NC 28403
TELEPHONE (910)798-6667FAX(910)798-7815
CHECKLIST FOR APPLICATIONFOR SEPTIC SYSTEMREPAIRPERMIT
New Hanover CountyHealth Department (NHCHD)Environmental Health Services (EHS) application formforImprovement Permit and Construction Authorization, Completelyfilled out and signed
Owner’sconsent to filing ofthis application, in writing, if applicant is not owner
Surveyor other legal map showingpropertydimensions, boundaries, and alleasements
Siteplan, drawn to scale,between 1 in. = 10ft and1 in. = 60 ft., showing allexistingand proposed development
Completed HomeownerInterview form
Waterbills from thelast six monthsor metered wellreadings (if requested)
Written documentation from thenearest provider of sewer/waterthat sewer/wateris NOT
available to the property
Location ofwater meterand waterlineto thestructureif served bypublicwater.
Locator servicehas beencontactedand has/will locate allundergroundpublicutilities on
(date)
Ifapplicant desires to reuse existingseptictank, it must be exposed to theinvert ofthe inlet and outlet prior to EHS evaluation
All wellheads cut offsub-surface(underground)mustbe exposed (dugup) to verify location
Propertyboundaries must be flagged or staked (flags provided)
I, (print name)certifythatI havefulfilled theabove-referenced application requirements and the propertyis preparedfora site evaluation.
(Signatureof applicant/owner)
“HealthyPeople, SafeEnvironment,Strong Community”
EHS090
12-2015
NEW HANOVER COUNTY ENVIRONMENTAL HEALTHSERVICESFEE SCHEDULE
Soil Evaluation / $281.00 *plus $100 each additional 600 gal/daySewage System Construction Authorization (Type I, II, III) / $280.00
Sewage System Construction Authorization (Type IV, V, VI) / $832.00 *plus $100 each additional 600 gal/day
*plus $100 X # inspections / 20 years
Sewage System Permit Revision / $140.00
Sewage System Repair Permit / $ 50.00
Existing System Inspection (Building addition or Private pool) / $140.00
Existing System Inspection (Reuse Purposes) / $140.00
Reissue or Revise Construction Authorization
Monitoring Soil Wetness Wells / $140.00
$300.00 per address per month
Land Record Review / $100.00 plus $50 each additional hour
Re-inspection after failed inspection at initial visit / $ 70.00
Well Permit ( Including site evaluation & bacterial analysis) / $350.00
Water Sample – Bacteriological / $140.00
Water Sample – Bacteriological / $ 70.00
Water Sample – Chemical / $140.00
Re-inspection after failed inspection at initial visit / $ 70.00
Food Service Plan Review
Prototype Restaurant & Food Stands / NC DENR – Division of EH approval letter
Non-prototype / Independent Restaurants, Food Stands & Mobile Food Units / $250.00
Renovations / Changes (dimension of food preparation area, seating capacity or addition to room) / $250.00
Temporary Food Establishment Permit / $ 75.00
Seafood Market Permit / $100.00
Seafood Vehicle Permit / $ 50.00
Swimming Pool – Operation permit / $200.00
Swimming Pool – Plan Review (new and existing remodel construction)
Swimming Pool – Plan Review (new and existing remodel construction) secondary and each resubmittal of rejected plan / $250.00
$250.00
Re-inspection after failed inspection at initial visit / $ 70.00
Tattoo Artist and/or Body Piercing Permit per location / $200.00
Tattoo Artist and/or Body Piercing per location paid less than 30 days prior to or after permit expiration / $300.00
Temporary Tattoo Artist and/or Body Piercing Permit / $100.00 ** operate 2 weeks or less
*First 600 gal/day **Permit to operate 2 weeks or less - Refund Request prior to provision of service will be granted on the basis of $10.00 filing charge EHS091 7-2017
DOCUMENTATIONTOAUTHORIZEANOWNER’SLEGAL REPRESENTATIVE
Applications for permitsrequire the“signatureoftheownerorowner’slegalrepresentative”(15A NCAC
18A .1937). If the ownerdoesnotsigntheapplicationhimselfor herself,theycan submitany oneof the followingdocuments todesignate theirlegalrepresentative:
1. Powerof Attorney
2. Real EstateContract
3. Estateexecutor
4. Bankruptcytrustee
5. Courtordered guardianship
Intheabsenceof theabovedocumentation, theproperty ownermayprovidethelocal health departmentwith documentationthatdesignatesalegal representative. Apropertyownermay:
1. Completethis formtodocument hisorher legalrepresentative,or
2. Providehisorherown form thatcontainstheinformationin thisform.
If therearemultiple propertyowners, then all propertyowners mustsigntheform thatdesignatesa legal representative.
6. Bysigning aform thatdesignates alegal representativefor purposesof15ANCAC 18A
.1937,theproperty ownerauthorizesthatrepresentativeto actontheir behalf in matterspertainingto theapplicationandpermittingprocess, includingsigningor receivinganyapplication, documentor permit. Theowner retains full responsibilityto meetall permitconditionsspecified bythelocalhealthdepartment.
I, , am thelegalowner(s)ofthepropertylocated at_ , identifiedas
PIN(ParcelIdentificationNumber) ,locatedinNewHanover
County,NorthCarolina.
I doherebyauthorize(printlegal representative/companyname) ,
_,toactasanagenton mybehalfin applying for/signing/obtaininganyof thedocumentsdescribedbelow.
Applicationfor Improvement Permit(IP) /AuthorizationtoConstruct(AC)
ImprovementPermit (IP) /AuthorizationtoConstruct(AC)
Applicationfor soil-site evaluation(new/repair)
Application/permitfor privatedrinking waterwell/well abandonment
ApplicationforComplianceInspection
I agreetoabidebyall decisions and/or conditions betweenthelegalrepresentativeactingonmybehalf andthe CountyDepartmentofPublicHealth, EnvironmentalHealth Division.
Signatureof Owner(s)DateSignatureof WitnessDate
EHS129
7/2016
HomeownerInterviewForm
Pleasefilloutcompletelytoassistintheevaluationofyourfailingsystem
Name_Date
Address Phone(H)
(W)
Whenwas septicsysteminstalled?
Permit#
Installerofcurrentsystem
Whenwasthelasttimeyoursystemtank waspumped?
SepticTankPumper
Howoftendoyouhaveyourseptictankpumped?
Whereinyouryardareyourseptictankanddrainfield:
Describewhatishappeningwhenyouare havinga problemwithyoursepticsystem:
Whendid you first noticethe problem?
Doestheproblemseemtobelinkedtocertainevents(heavyrains,washingclothes,companystayingover)ordoes it occuratcertaintimesofthedayorweek? Explain:
Howmanypeoplelivein your house?
Adults
Children
Teens
Howmuchwaterdoyouuseeachday?
Are youonpublic water?
Howmuchisyourmonthlywaterbill?
Doyouhaveagarbagedisposal?
Howoftendoyouuseit?
Doyouhavea dishwasher?
Howoftendoyouuseit?
Doyouhaveawashingmachine?
Howmanyloadsperweekdoyou wash?
Do youusean “inthetank”or“inthebowl”toiletbowlsanitizer?
Doyouhaveawatersoftenerorwatertreatmentsystem?
Wheredoesitdrain?
Isthis yourfirstexperienceutilizinga septicsystem? YesNo
Areanyhouseholdcleaningchemicalsputdownthedrain?
Whatkinds?
Areanychemicals,paintthinners,paints,etc.,disposeddownthedrain?
Whatkinds?
Haveanynewwaterusingfixturesbeenaddedsincethesystemwasinstalled?
Whatkinds?
Pleaselistanyplumbingfixtures(likespasorwhirlpools)otherthansinks,lavatories,showers/bath
toilets:
Doyouhaveanundergroundlawn-wateringsystem?
Hasanysite workbeendonetothe housesinceyoumovedin, suchas gutterdrains,a newpool,basementor foundationdrains,landscaping,pavingofdriveway?
Describe:
Arethereanyundergroundutilitiesonyourlot?
Checkwhichones:
PowerPhoneCableGasWater
Signature
MEMORANDUM
TO:Applicants For Septic System Repair Permits
FROM:Catherine Timpy, Senior Environmental Health Program Specialist
DianneHarvell,EnvironmentalHealthServicesManager
DATE:September 14,2001
SUBJECT:Wells, water and otherutilitylines
Pleasebe advised that applications forsepticsystem repair permitswillbereviewed/site inspected AFTER theapplicant has locatedallutilitylines which mayinterferewith the installation of anyrepair. Theseincludewaterlines(includingirrigation lines) electric, telephone, cable, etc. Thereis a utilitylocatingservice availableat no charge, which will locate power lines, except private lines, cableandtelephonelines. It is North CarolinaOne Call(“No Cuts”) and theirtelephonenumber is 1-800-632-4949. Theapplicant is to notify the Health Departmentwhen this iscompleted. Thesitewillthen bevisited for purposes
of evaluatingthe area available forasepticsystem repair. Hopefully, thisprocedurewill eliminate theneed to make adjustments at thetime ofinstallation and avoid undue costs.
Additionally, at this time, itshould benoted that theStateLaws and RulesforSewage Treatment andDisposal Systems (15ANCAC 18A.1950(a)14) requires that anypart ofaseptic system beat least 10 feetfrom ANY waterline. This means irrigation systems crossingseptic tanks and drainfieldsmust be relocated at least 10feet away. Theonlydeviation from this is under .1950(f), which allows for asupplylineto crossawater lineif constructed ofductile
iron pipe OR 18 inches of separation can bemaintained, with the sewagesupplyline crossing beneath.
Therules also requireaminimum distanceof 50feet awayfromanypartof asepticsystem to anywatersupplywell(.1950(b). This includes irrigationwells. A wellof anytypewhich is located closer than 50 feet to an existingseptictank and/ or drainfield will either haveto be abandoned bya certifiedwelldriller, and theabandonment logsubmitted to thisoffice ORthe septictank must berelocated at least 50 feet awayfrom thewell. Theauthorization to construct maybeissuedafter thewellis abandoned, if the applicant doesnot relocate the
septictank.
Ifyou haveanyquestions, please contact us at 798-6667.
Revised 2/16/2007