LAND USE 0
NAME: ___Jlk r CLCL L Raj( ICJ Cs"tt APPLICATION #: r" i of `C 3 9
*This application to be filled out when applying for a septic system inspection.*
County Health Department Application for Improvement Permit and/or Authorization to Construct
IF THE INFORMATION IN THIS APPLICATION IS FALSIFIED, CHANGED, OR THE SITE IS ALTERED, THEN THE IMPROVEMENT
PERMIT OR 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)
910- 893 -7525 option I CONFIRMATION #
Environmental Health New Septic System Code 800
• Place "pink property flags" on each corner iron of lot. All property lines must be clearly flagged approximately
every 50 feet between corners.
1 • Place "orange house corner flags" at each corner of the proposed structure. Also flag driveways, garages, decks,
out buildings, swimming pools, etc. Place flags per site plan developed aVfor Central Permitting.
• Place orange Environmental Health card in location that is easily viewed from road to assist in locating property.
• If property is thickly wooded, Environmental Health requires that you clean out the undergrowth to allow the soil
evaluation to be performed. Inspectors should be able to walk freely around site. Do not grade property.
• Call No Cuts to locate utility lines prior to scheduling inspection. 800- 632 -4949 (This is a free service)
• After preparing proposed site call the voice permitting system at 910 - 893 -7525 option 1 to schedule and use code
800 (after selecting notification permit if multiple permits exist) for Environmental Health inspection. Please note
confirmation number given at end of recording for proof of request,
• Use Click2Gov or IVR to verify results. Once approved, proceed to Central Permitting for permits.
IJ Environmental Health Existing Tank Inspections Code 800
• Follow above instructions for placing flags and card on property.
• Prepare for inspection by removing soil over door as diagram indicates. Loosen trap door cover. (Unless
inspection is for a septic tank in a mobile home park)
• After preparing trapdoor call the voice permitting system at 910 - 893 -7525 option 1 & select notification permit if
multiple permits, then use code 800 for Environmental Health inspection. Please note confirmation number
given at end of recording for proof of request.
• Use Click2Gov or IVR to hear results. Once approved, proceed to Central Permitting for remaining permits.
SEPTIC
If applying for authorization to construct please indicate d sired system type(s): can be ranked in order of preference, must choose one.
I —) Accepted 1 -1 Innovative Conventional 1_) Any
1_1 Alternative { Other
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 is "yes", applicant must attach supporting documentation.
1 _ 1 YES I 'L ) NO Does the site contain any Jurisdictional Wetlands?
I _)YES 1%J NO Do you plan to have an jnipallQ .system now or in the future?
1_) YES (XI NO Does or will the building contain any cl ajll ? Please explain.
)_I NO NO Are there any existing wells, springs, waterlines or Wastewater Systems on this property?
I_)YES 125 NO Is any wastewater going to be generated on the site other than domestic sewage?
I —IYES Ix) NO Is the site subject to approval by any other Public Agency?
I_IYES {.) NO Are there any easements or Right of Ways on this property?
(_}YES {i NO Does the site contain any existing water, cable, phone or underground electric lines?
If yes please call No Cuts at 800- 632 -4949 to locate the lines. This is a free service.
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 Lan And Rules.
1 Understand That 1 Am Solely Responsible For The Proper Identification And Labeling Of All Property Lines And Corners And Making
The Site Accessible So Th A Complete Site Ev to i Can Be Performed. 921.9___
PROPERTY OWNERS ) R OWN S ,ECAL REPRESEN'PATIVF. SIGNATURE (REQUIRED) DATE
5/08
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