Office use only: to make application for environmental health services you must submit a plat or site plan drawn to scale of your property with this application


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NameOffice use only: to make application for environmental health services you must submit a plat or site plan drawn to scale of your property with this application
A typeDocumentation
APPLICATION FOR ENVIRONMENTAL HEALTH SERVICES - NHC FILE NO_______________
PLEASE PRINT
Name: _______________________________ Mailing Address: _________________________________City/State/Zip___________
Home Phone: __________________Business/Mobile Phone:________________ E-mail Address: _____________________________
Street Address for Site: ___________________________Zip: _________Subdivision: __________________ Lot/Section: _________
Directions to Property: _________________________________________________________________________________________
________________________________________________County Sewer: (YES) (NO) Tax Parcel #______________

Installation for: Lot Size: _______________________ Industry of Business:

Residence: ________________ No. of Bedrooms: ________________ Number of Employees: ____

Industrial / Commercial ______ (Type) ___________ Private Well: (YES) (NO) Number/Type of water using

Duplex: __________________ Public System Name: _____________ fixtures: ________________
OFFICE USE ONLY: TO MAKE APPLICATION FOR ENVIRONMENTAL HEALTH SERVICES YOU MUST SUBMIT A PLAT OR SITE PLAN DRAWN TO SCALE OF YOUR PROPERTY WITH THIS APPLICATION.

Mobile Home Replacement ________

Building Addition/Conversion ________

Swimming Pool (Private) ________ Please show the location of the residence or building, including

Well Abandonment ________ driveways, and any other improvements/additions (pools, decks, etc.)

Well Permit (new / replacement) ________

Well Repair/Reconstruction ________ Permits issued pursuant to this application shall not be

Water Sample (Bacteriological) ________ affected by change in ownership provided the site plan remains

Water Sample (Inorganic) ________ unchanged.

Water Sample (Resample) ________ Please submit storm water plans for Subdivisions and Commercial Developments.

Permit Revision ________

The undersigned person hereby agrees that he/she has read this application.

It is understood that any permit issued hereafter are subject to suspension

Amount Received: $ __________ Receipt #: _______ or revocation if the site plans or the intended use change or if the information

Cash _____ Check # __________ Credit Card ______ submitted on this application is falsified.



Date of Application Owner / Agent EHS075

8-2008

NEW HANOVER COUNTY ENVIRONMENTAL HEALTH SERVICES FEE SCHEDULE


Soil Evaluation

$281.00 *plus $100 each additional 500 gal/day

Sewage System Construction Authorization (Type I, II, III)

$280.00

Sewage System Construction Authorization (Type IV, V, VI)

$832.00 *plus $100 each additional 500 gal/day

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

$140.00

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 facility construction

$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

Tattoo Artist and/or Body Piercing Secondary Permit @ alternate location

$125.00 ***

Temporary Tattoo Artist and/or Body Piercing Permit


$100.00 **** operate 2 weeks or less



* First 500 gal/day EHS091

** Second & subsequent facility @ same address 25% reduction 7-2013

*** Tattoo and/or Body Piercing Shop under same ownership

**** Permit to operate 2 weeks or less

NEW HANOVER COUNTY

HEALTH DEPARTMENT


Environmental Health Services

230 Government Center Dr., Suite 140

Wilmington, NC 28403

TELEPHONE (910) 798-6667 FAX (910) 798-7815

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CHECKLIST FOR APPLICATION FOR REUSE OF EXISTING SEPTIC/WELL

(INCLUDES BUILDING ADDITIONS/CONVERSIONS, MOBILE HOME REPLACEMENTS, SWIMMING POOLS)

____ New Hanover County Health Department (NHCHD) Environmental Health Services

(EHS) application form (blue), completely filled out and signed
____ Owner’s consent to filing of this application, in writing, if applicant is not owner
____ Survey or other legal map showing property dimensions, boundaries, and all easements
____ Site plan, drawn to scale, between 1 in. = 10 ft. and 1 in. = 60 ft., showing all existing and proposed development. Include any existing septic systems and wells. Include all plumbing connections to sewer.
____ The lot must be cleared to allow visibility and access by foot AND the property boundaries must be flagged or staked (flags will be provided). Edge of easement(s) must be marked in the field.
____ Proposed addition to the property must be flagged or staked (flags will be provided).
____ Septic tank exposed to the invert of the inlet and outlet of the tank (If not stamped, may require verification of liquid volume of tank)
____ Well heads underground located and exposed
____ Provide documentation from nearest provider of public sewer and/or water that connection is not mandated. Without this, EHS cannot proceed with the processing of the application.

I, _____________________________________________________(print name) certify that I have fulfilled the above-referenced application requirements and the property is prepared for a site visit.____________________________________________________________________

Signature of applicant/owner
EHS101

12-2015


NOTICE TO APPLICANTS

FOR

ENVIRONMENTAL HEALTH SERVICES

ONSITE WASTEWATER PERMITS

PURSUANT TO 15A NCAC 18A .1937(d),

APPLICANTS SHALL PROVIDE WRITTEN PERMISSION AND SIGNATURE OF PROPERTY OWNER AUTHORIZING APPLICANT AS LEGAL REPRESENTATIVE IN THE APPLICATION PROCESS IF APPLICANT IS NOT CURRENTLY THE OWNER OF RECORD OF THE SUBJECT PROPERTY.

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