COUNTY OF RANDOLPH
Health Department
204 E Academy St - Asheboro NC 27203
LOCAL TELEPHONE NUMBERS
Asheboro: (336) 318-6262 ● Archdale/Trinity: (336) 819-3262
http://www.randolphcountync.gov
Application for Subsurface Wastewater Repair Permit (EHS 3) Rev. 9/6/2019
APPLICATION FOR SUBSURFACE WASTEWATER REPAIR PERMIT
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 the documentation submitted. (Complete site plan=60 months;
Complete plat=without expiration.)
Applicant: ________________________________ Date: ____________________________________
Address: __________________________________ Application #: ______________________________
City, ST ZIP _______________________________ Parcel number: ____________________________
Owner: __________________________________ Contact name: ____________________________
Address: _________________________________ Contact phone: ____________________________
City, ST ZIP ______________________________ Contact e-mail: ____________________________
LOCATION INFORMATION:
Location: ________________________________________________________________________________
Subdivision: ______________________________ Lot number: ______________________________
FACILITY INFORMATION:
Proposed Use: ____________________________ Water Supply: _____________________________
If other, Specify: ___________________________ Site Contain Wetlands: ______________________
Number of Bedrooms: _______________________ Existing Wells Present: ______________________
Number of People/Employees: ________________ Existing Easements Present: _________________
Number of Shifts: __________________________ Domestic Wastewater Only: __________________
Number of Seats: __________________________ Existing Septic System Type: _________________
Number of Toilets/Urinals: ___________________ Age of Septic System: ______________________
Number of Showers/Tubs: ___________________ Location of Septic System: ___________________
Existing Structures: _________________________ Nature of Failure: __________________________
COMMENTS: ____________________________________________________________________________
________________________________________________________________________________________
AUTHORIZATION TO PROCEED:
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. You must provide documentation to support claim as owner’s legal representative.
_____________________________________________ ___________________________________________
Signature of property owner/legal representative* Date
*You must provide documentation to support claim as owner’s legal representative.
Existing easements present
Location of septic system
click to sign
signature
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