Check List for Existing System Inspection If you have an existing septic tank or well on a private lot or in a mobile home park, before you can obtain a building permit to do either of the following: a) set up a mobile home, b) build a house or modular home, c) add an addition to a house, mobile home or any other type of building, d) construct a building, e) pour any type of cement/concrete pad [such as for a dog lot], f) install a swimming pool, or g) restore electrical service you must contact Environmental Health at (336) 570-6367 for a Registered Environmental Health Specialist to do an existing system inspection. 1. Complete application (FORM MUST BE FILLED OUT COMPLETELY). 2. The site plan should show setbacks to the two closest property lines, or if it is a large tract of land, to two permanent structures. If the structure that is being built is close to a property line, you will need to call Building Inspections to check their setbacks before applying with our office. 3. Pay $75 fee for private lot $75 fee for Mobile Home Park. 4. Any changes - all types of structures such as buildings, swimming pools, additions, etc. MUST BE CLEARLY IDENTIFIED/STAKED OFF ON THE PROPERTY. 5. PROPERTY CORNERS MUST BE CLEARLY IDENTIFIED. If property lines or the new structure is not clearly marked, a revisit fee of $70 could be assessed. 6. Prior to Environmental Health visiting the lot call 811 to mark your utilities. 7. Registered Environmental Health Specialist will go out to the property and either approve or deny the system. 8. The Registered Environmental Health Specialist will issue an Existing Sewage System Authorization permit and will notify you when the paperwork is complete. This permit will be valid for 6 months from the issue date. This paperwork will be needed for the Building Inspections Department in your jurisdiction to obtain the necessary permits. If the number of existing bedrooms is to be increased, then a soil evaluation/upgrade application must be completed - fee is $240. Refer to site/soil evaluation procedures. Please Note: We accept checks, money orders, cash or Visa & MasterCard. Please make check payable to: Alamance County Health Department. PLEASE BE ADVISED THAT ALL PAYMENTS ARE FINAL AND NO REFUNDS OR TRANSFER OF FUNDS ARE POSSIBLE. BY SIGNING AND SUBMITTING YOUR PAYMENT YOU ARE AGREEING TO THESE TERMS AND CONDITIONS.
Alamance County Health Department Environmental Health Section 209 N. Graham-Hopedale Road Burlington, NC 27217 Fax: (336) 570-6362 Phone: (336) 570-6367 www.alamance-nc.com REQUEST FOR SERVICES Tax Map Number: GPIN: Requestee's Name: Address: Telephone #: Cell #: Email Address: Owner's Name: Address: Telephone #: Cell #: Email Address: Directions to Property: TYPE OF SERVICE NEEDED EXISTING SYSTEM INSPECTIONS - Circle the building type and complete the information on the next page. House - ($75) Mobile Home - ($75) Business - ($75) Mobile Home Park ($75) Required for survey plat ($75) A plat or a survey map must accompany this application. Type of Water Supply: Drilled Bored Hand Dug Spring Public Don t know Clearly locate and flag all property corners and lines and corners of proposed structure. Requestee is strongly encouraged to determine and comply with any applicable zoning authority having jurisdiction over this property and comply with any and all requirements which will need to be met before any improvements are made to this property. I have read this application and certify that the information provided herein is true, complete, and correct to the best of my knowledge, and is given in good faith. I understand that any or all permits applied for or granted shall be void if any of the information is incorrect or false. Permission is granted for Health Department Personnel to perform the necessary evaluations and inspections on the property. PLEASE BE ADVISED THAT ALL PAYMENTS ARE FINAL AND NO REFUNDS OR TRANSFER OF FUNDS ARE POSSIBLE. BY SIGNING AND SUBMITTING YOUR PAYMENT YOU ARE AGREEING TO THESE TERMS AND CONDITIONS. Owner/Applicant Signature: Date: We accept cash, checks, money orders, VISA & MasterCard. Please make check payable to: Alamance County Health Department Mail application to: Environmental Health Section 209 N. Graham-Hopedale Road, Burlington, N.C. 27217
SUPPLEMENTARY INFORMATION FOR EVALUATION OF EXISTING SEPTIC SYSTEM 1) Moving a mobile home in a mobile home park: Name of Park: Lot Number: 2) Locating or replacing a mobile home on a vacant private lot served by an existing septic system. Number of bedrooms in original residence on the site: Number of bedrooms in proposed residence on the site: Number of residents: Dimensions of proposed mobile home or house: If a house, will it have a basement? Yes No 3) Need electrical service restored: 4) Adding sleeping area to existing residence: Current number of bedrooms: Number of bedrooms after addition is complete: 5) Other (give details): Please give us the following information: 1) Under what name or names might we find any septic tank permits from when the septic tank system was originally installed or repaired? Any information you can provide to us (name of builder, septic system installer, location of septic system, dates, etc.) may help to speed the septic system check process. Alamance County Printing Services EVH0001.P65-DD
SAMPLE SITE PLAN If you are applying for an Existing System Check, you will be asked to provide us with a Site Plan. Below you will find a sample site plan to assist you in preparing yours. Before we visit your property, we must have a site plan showing the items below. The site plan you prepare is required for us to complete your request. Please show the exact location where you would like to locate the addition or where you plan to place the pool, garage, mobile home, etc. You also must show on your site plan the current location of your well, septic system, waterlines, and other underground utilities. Don t forget to show your property corners and property lines. If you have any questions, please call us at (336) 570-6367. Septic System 10 Underground Power Easement 200 Septic System Drainfield 250 Septic tank 250 Well X 50 75 Three Bedroom House 30 X 50 Neighbor s Well D R I V E W A Y Well Well X 200 Main Street
Site Sketch
ALAMANCE COUNTY ENVIRONMENTAL HEALTH APPLICATION FOR PERMITS PROPER PHOTOGRAPHIC IDENTIFICATION IS REQUIRED I certify that I am the owner, have contracted to purchase, or have been contracted by the owner of the property to provide a service on the property referenced herein and that such service requires a permit issued by the Alamance County Health Department for the following permits: Soil/Site Evaluation- Improvement; Authorization to Construct; Well Permit; Manufactured Home Park Permit; Existing Wastewater System Inspection; Water Sample; Tattoo; Swimming Pool; Swimming Pool Plan Review; Food Services, Child Care, Rest Home, etc., Food Service Plan Review and Permit. Name Phone # (Applicant) Mailing Address Agency/Firm Property Owner (If different From Applicant) I certify that all of the information set forth on this form is accurate. (Signature) DOB ID Verified By: (NC Driver s License or Photo ID) (Initial)
AUTHORIZATION TO ACT AS AGENT FOR OWNER Any application/document/permit requiring a signature must be signed by the property owner or their authorized agent. This form shall be provided by the owner to allow specified individuals to act as agents for the owner. This form allows the specified individuals to sign or receive any application/document/permit on behalf of the owner. This form allows the authorized agent to make decisions on behalf of the owner pertaining to modifications of permits in the field. It is the responsibility of the owner to assure that any/all permit conditions specified on permits issued by Alamance County Environmental Health are followed. I,, am the legal owner of the property located at, identified as TMN (Tax Map Number), located in Alamance County, North Carolina. I do hereby authorize (print authorized agent/company name) to act as an agent on my behalf in applying for/signing/obtaining any of the documents described below. 1. Improvement Permit (IP)/ Authorization to Construct (AC). 2. Application for soil-site evaluation (new/repair). 3. Application/permit for water well/well abandonment/well repair. 4. Application for existing system check. 5. Application for Improvement Permit (IP)/ Authorization to Construct (AC). 6. Application for water sample(s). I agree to abide by any and all decisions and/or conditions between the agent acting on my behalf and the Alamance County Health Department, Environmental Health Section. This form must be fully executed before the individuals specified above will be recognized as the authorized agent. Signature of Owner Signature of Witness Date Date