Caldwell County Health Department
Assigned To: ______________________ *Complete survey plat to scale submitted Date _________________
For office use only unscaled site plan submitted NC PIN# _______________
IP Number: ___________________ Scaled site plan submitted (1” ≤ 60’) Original Permit # _________________
Caldwell County Health Department
Application for Septic Improvement Permit and/or Construction Authorization Initial one: _____ IP only _____CA only ________CA only – Name Change** Check one: New System* Expansion of existing* Repair
______ Both IP and CA Reconnect
*These applications must include an approved site plan (see site plan checklist and example on page 2) ** Must use site plan from original CA
This application is nontransferable and remains valid for 2 years Improvement permits are transferable and valid for 60 months Improvement permits are without expiration if issued in conjunction with a complete survey plat depicting all improvements including septic and well areas to scale and filed with the Register of Deeds. Construction Authorization is valid for the length of the improvement permit but is not transferable Once issued, alterations in the site or site plan may invalidate the IP and/or CA
Applicant Information (Permits are issued to the applicant) _______________________________________________ Owner / Applicant
___________________________________________ ________________________ Address Home & Work Phone
________________________________________________ __________________________________________ _______________________ Applicant / Agent Address Home & Work Phone -----------------------------------------------------------------------------------------------------------------------------------------------Property Information Lot Size: _________________ _________________________________________________ Street Address
_____________________________________ Subdivision Name
_________________ Section/Phase/Lot#
Directions to Site: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________
Residential Specifications Max number of bedrooms: _________ House Max number of occupants: _________ Mobile Home If expansion: Current number of bedrooms: _______ Modular Will there be a basement? yes no Multi-family – No of Units _______ Plumbing Fixtures in Basement yes no Non-Residential Specifications: Maximum number of employees: ___________ Total Square Feet of Building ___________ Restaurant/ Assembly – No. of seats____________ Sq. Feet of Dining Area ____________ Food Stand - Sq. Feet of Food Stand ____________ Day Care -No. of Children / Adults____________ Institution Storage Industry Educational Hazardous Pool Other: ___________________ Water Supply: New well Existing Well Community Well Public Water Spring Desired System Type (systems can be ranked in order of your preference) Alternative Conventional Innovative Modified Conventional Other (specify) 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. Check yes or no for each question below. If the answer to any question is “yes”, applicant must attach supporting documentation. yes no Does the site contain any jurisdictional wetlands? yes no Is any wastewater going to be generated on the site other than domestic sewage? yes no Is the site subject to approval by any other public agency? yes no Are there any easements or right of ways on this property?
Page 1 of 2
Site Plan Checklist - To ensure your site plan is complete, place a mark () beside each item that has been indicated on your site plan. Enter “N/A” if the item does not apply. Existing and proposed property lines with dimensions. Indicate the location of any property irons or survey markers The location of all existing and proposed structures and appurtenances with dimensions (e.g. house, garage, driveway, pool, outbuildings, etc.) If you are unsure as to the proposed structure size, please show the dimensions of the MAXIMUM area on the lot that you anticipate the structure will cover Show the distances from all proposed structures to two fixed reference points (e.g. irons, power poles, existing structures, etc.) or from nearest property lines or road. The site you would prefer your septic system go in (tank and nitrification field) The location of any existing septic tank systems or wells on your property and wells on the adjoining property within 100’ of your property line. The location of any surface bodies of water(e.g. spring, creek, pond) The location of any easements (including electrical), rights of way, or building setbacks on the property The location of any grading or proposed grading (removal or addition of soil) If your parcel is a large tract of land, indicate the location of the site you have prepared on the map provided by our office using an asterisk (*).
Example Site Plan
I acknowledge that I have read this application and the site prep instructions provided to me. I certify that the information provided on this application and the attached site plan (if applicable) is true, complete and correct. I understand that if the information or site plan provided by me is falsified or changed, then permits issued based on that information shall become invalid. With this application, authorized county and state officials are granted right of entry to conduct necessary inspections to determine compliance with applicable laws and rules. NOTE: In issuing or denying permits for septic systems, Environmental Health Specialists, although employed by Caldwell County, are acting as agents of the State of North Carolina, and are applying rules and regulations promulgated by the State.
__________________________________________________________________________________________ Property owner’s or owner’s legal representative** signature (required)
**Must provide Caldwell County Authorized Agent form to claim as owner’s legal representative.
________________ Date
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For office use only unscaled site plan submitted NC PIN# _______________
IP Number: ___________________ Scaled site plan submitted (1” ≤ 60’) Original Permit # _________________
Caldwell County Health Department
Application for Septic Improvement Permit and/or Construction Authorization Initial one: _____ IP only _____CA only ________CA only – Name Change** Check one: New System* Expansion of existing* Repair
______ Both IP and CA Reconnect
*These applications must include an approved site plan (see site plan checklist and example on page 2) ** Must use site plan from original CA
This application is nontransferable and remains valid for 2 years Improvement permits are transferable and valid for 60 months Improvement permits are without expiration if issued in conjunction with a complete survey plat depicting all improvements including septic and well areas to scale and filed with the Register of Deeds. Construction Authorization is valid for the length of the improvement permit but is not transferable Once issued, alterations in the site or site plan may invalidate the IP and/or CA
Applicant Information (Permits are issued to the applicant) _______________________________________________ Owner / Applicant
___________________________________________ ________________________ Address Home & Work Phone
________________________________________________ __________________________________________ _______________________ Applicant / Agent Address Home & Work Phone -----------------------------------------------------------------------------------------------------------------------------------------------Property Information Lot Size: _________________ _________________________________________________ Street Address
_____________________________________ Subdivision Name
_________________ Section/Phase/Lot#
Directions to Site: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________
Residential Specifications Max number of bedrooms: _________ House Max number of occupants: _________ Mobile Home If expansion: Current number of bedrooms: _______ Modular Will there be a basement? yes no Multi-family – No of Units _______ Plumbing Fixtures in Basement yes no Non-Residential Specifications: Maximum number of employees: ___________ Total Square Feet of Building ___________ Restaurant/ Assembly – No. of seats____________ Sq. Feet of Dining Area ____________ Food Stand - Sq. Feet of Food Stand ____________ Day Care -No. of Children / Adults____________ Institution Storage Industry Educational Hazardous Pool Other: ___________________ Water Supply: New well Existing Well Community Well Public Water Spring Desired System Type (systems can be ranked in order of your preference) Alternative Conventional Innovative Modified Conventional Other (specify) 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. Check yes or no for each question below. If the answer to any question is “yes”, applicant must attach supporting documentation. yes no Does the site contain any jurisdictional wetlands? yes no Is any wastewater going to be generated on the site other than domestic sewage? yes no Is the site subject to approval by any other public agency? yes no Are there any easements or right of ways on this property?
Page 1 of 2
Site Plan Checklist - To ensure your site plan is complete, place a mark () beside each item that has been indicated on your site plan. Enter “N/A” if the item does not apply. Existing and proposed property lines with dimensions. Indicate the location of any property irons or survey markers The location of all existing and proposed structures and appurtenances with dimensions (e.g. house, garage, driveway, pool, outbuildings, etc.) If you are unsure as to the proposed structure size, please show the dimensions of the MAXIMUM area on the lot that you anticipate the structure will cover Show the distances from all proposed structures to two fixed reference points (e.g. irons, power poles, existing structures, etc.) or from nearest property lines or road. The site you would prefer your septic system go in (tank and nitrification field) The location of any existing septic tank systems or wells on your property and wells on the adjoining property within 100’ of your property line. The location of any surface bodies of water(e.g. spring, creek, pond) The location of any easements (including electrical), rights of way, or building setbacks on the property The location of any grading or proposed grading (removal or addition of soil) If your parcel is a large tract of land, indicate the location of the site you have prepared on the map provided by our office using an asterisk (*).
Example Site Plan
I acknowledge that I have read this application and the site prep instructions provided to me. I certify that the information provided on this application and the attached site plan (if applicable) is true, complete and correct. I understand that if the information or site plan provided by me is falsified or changed, then permits issued based on that information shall become invalid. With this application, authorized county and state officials are granted right of entry to conduct necessary inspections to determine compliance with applicable laws and rules. NOTE: In issuing or denying permits for septic systems, Environmental Health Specialists, although employed by Caldwell County, are acting as agents of the State of North Carolina, and are applying rules and regulations promulgated by the State.
__________________________________________________________________________________________ Property owner’s or owner’s legal representative** signature (required)
**Must provide Caldwell County Authorized Agent form to claim as owner’s legal representative.
________________ Date
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