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Updated Rowan County EH Application
Application for Services
NOTICE:
CDP Number - For Office Use Only
Applicant - do not enter data into this field.
Form of Payment and Amount - For Office Use Only
Applicant - do not enter data into this field.
Date Payment Received - For Office Use Only
Applicant - do not enter data into this field.
Property Address
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Subdivision (Name; Section/Phase; Lot #) - If Appilcable
Township (Map; Parcel ID)
Property Information (Lot Size & Date originally deeded & recorded)
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Applicant Name
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Applicant Phone
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Email
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Applicant Address
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Street Address
City
State / Province / Region
Postal / Zip Code
Owner (Name & Phone)
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If different from Applicant, an authorization form is needed. Click link to obtain form.
Owner Address
Street Address
City
State / Province / Region
Postal / Zip Code
Directions to Property from Major Road, Intersection, or Landmark (I-85, Hwy 29, Jake Alexander, etc.)
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Development Information - What are you applying for? Choose all that apply.
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New Single Family Residence - Septic (will require Preliminary Zoning Permit)
Expansion of Existing System - Adding Bedrooms(s)
Repair to Malfunctioning Sewage Disposal System
Non-Residential Type of Structure (will require Preliminary Zoning Permit)
New Well
New Multi-Family Residence - Septic (will require Preliminary Zoning Permit)
Existing System Inspection- for Mobile Home (will require Preliminary Zoning Permit)
Existing System Inspection - addition to or new residence (will require Preliminary Zoning Permit)
Residential Specifications:
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Max Number of Bedrooms:
Max Number of Occupants:
If expansion: Current number of bedrooms:
Number of Bedrooms to be added
Will there be a basement?
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Yes
No
If yes, complete the next field.
Plumbing fixtures in basement?
Yes
No
Non-Residential Specifications: (Complete only if applying for non-residential)
Type of business (what service does this business provide?):
Max Number of employees:
Total square footage of building:
Maximum Number of seats:
Current Water Supply:
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None
Existing Well
Community Well
Public Water
Spring
Shared Well
Other Information:
When was system installed?
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In whose name?
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Has system been repaired?
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Yes
No
In whose name?
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When was it repaired?
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Is there a well on the property?
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Yes
No
Number of homes well serves
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Is the well cutoff below ground level?
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Yes
No
Any septic systems or buried fuel tanks within 50' of well?
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If applying for Authorization to Construct Septic System:
Please Indicate Desired System Type(s):
(systems can be ranked in order of your preference)
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Conventional/Accepted
Alternative
Innovative
Other
Any
Comments related to above:
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.
Does the site contain any jurisdictional wetlands?
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Yes
No
Does the site contain any existing wastewater systems?
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Yes
No
Is any wastewater going to be generated on the site other than domestic sewage?
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Yes
No
Is the site subject to approval by any other public agency?
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Yes
No
Are there any easements or right of ways on this property?
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Yes
No
Are there any existing wells, springs, or existing waterlines on this property?
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Yes
No
Unknown
Are there any known underground contamination sources on this property?
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Yes
No
Unknown
Are there any current or pending restrictions regarding groundwater use for this property?
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Yes
No
Unknown
Are there any variances regarding well construction or location for this property?
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Yes
No
Unknown
Additional Comments:
ATTENTION:
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) 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. *FOR NEW WELL CONSTRUCTION· PROPERTY OWNER IS RESPONSIBLE FOR CONTACTING THE ASSIGNED ENVIRONMENTAL HEALTH SPECIALIST TO INFORM THEM THAT THE WELL HAS BEEN CHLORINATED, IS IN USE, AND IS READY FOR WATER SAMPLES TO BE TAKEN.*
Signature & Date
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Property owner's or owner's legal representative** signature (required)
**Must provide documentation to support claim as owner's legal representative.
ROWAN COUNTY ENVIRONMENTAL HEALTH SITE PLAN WORKSHEET
Remember: Your property will not be scheduled for an evaluation until we have received a complete application , site plan and all proposed Items are marked on the property.
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I Agree
The dimensions of the property.
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I Agree
The proposed location of all structures (e.g.facility, wells, water lines, out buildings, pools, etc.). Show the distances from the road and the side property line to all structures. Be sure to give the dimensions for all the structures.
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I Agree
If you are unsure as to the structure size, please show the dimensions of the MAXIMUM area of the lot that you anticipate the structure will cover.
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I Agree
The preferred septic system location.
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I Agree
The preferred driveway location.
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I Agree
Any proposed structures or Improvements to the property such as garages, workshops, pools, etc.
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I Agree
The location of any existing septic systems and wells on your property and on the adjoining property within 100' of your property line.
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I Agree
The location of any easements or rights of way on the property.
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I Agree
The location of any designated wetlands on the property.
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I Agree
The location of any burled debris pits on the property.
Drawing
File Upload
Additional Requirements:
15A NCAC 18A .1937 (d) The application for an Improvement Permit shall contain at least the following Information: owner's name, mailing address, phone number, location of the property, plat of property or site plan, description of existing and proposed facilities or structures, number of bedrooms, or number of persons served, or other factors required to determine wastewater system design flow or wastewater characteristics, type of water supply Including the location of proposed or existing well(s), and signature of owner or owner's legal representative. The applicant shall Identify property lines and fixed reference points In the field. The applicant shall make the site accessible for an evaluation as required in Rule .1939 of this Section. The applicant shall notify the local health department on the application of the following:: 1) the property contains previously Identified jurisdictional wetlands; 2) wastewater other than sewage will be generated; or 3) the site Is subject to approval by other public agencies.
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Applicant Name & Signature
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ENVIRONMENTAL HEALTH REQUIREMENTS FOR SEPTIC AND WELL PERMITS
The following Items must be completed prior to the submittal of any Environmental Health Application. Incomplete applications will be returned to the applicant and cannot be processed or placed on the work list. Check all lines below to indivate you have submitted each form and completed every site requirement.
The following forms have been submitted:
Application
Site Plan with dimensions of proposed structure, addition, pool etc.
Documentation to Authorize Owner Agent (if the property owner Is not the applicant)
Copy of Zoning Permit, when applicable
Sign this sheet after you have completed all Items
Lot Clearing
Lot must be cleared of heavy undergrowth. In order to evaluate the lot, the footprint of the proposed structure must be visible. Adequate area for the septic drain field and repair area must be sufficiently cleared of heavy undergrowth, with 50 feet
Clearly Marked
Clearly mark all property comers by locating existing Iron or concrete markers. Flag all property lines every 25 feet If adjacent comers are not visible when standing on any given comer.
Property fines must be flagged by a licensed NC surveyor & easily Identified prior to application submittal. Mow fines and/or fence lines do NOT constitute marked lines.
If the property lines are not property marked when the lot is ready to be evaluated, then the application will be put on hold and a site re-visit fee charged.
Staked
Stake or flag the footprint of the proposed structure, addition, pool etc. to match the site plan submitted. The proposed structure, etc. must be staked out on the property as per the site plan.
If the lot is not adequately cleared and house/property lines sufficiently marked, then a site revisit fee will be charged and the evaluation will be put on hold until the requirement is met.
Authorization to Construct
If an Authorization to Construct is desired, submit a recorded copy of the plat for newly created or subdivided lot(s) and a LEGIBLE copy of the site including decks, porches, etc. The overall dimensions of the property & structure must be noted.
Final Notes:
When an Expansion Application is submitted, all utilities shall be marked before soil can evaluated. Call NC 811 for this service. The applicant/agent is responsible for securing these services. If backhoe pits are required to be dug at the locations, pit depths will be determined by the Environmental Health Specialist or a NC Licensed Soil Scientist. A minimum of three pits must be dug. Zoning Permit can be obtained from Planning and Zoning Department.
Signature & Date
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Clear
If additional questions, contact the Environmental Health Offices at 704.216.8525.
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