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 Disposal Permit (EHS 1) Rev. 9/6/2019
APPLICATION FOR SUBSURFACE WASTEWATER DISPOSAL 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: ____________________________ Number of Showers/Tubs: ___________________
If other, Specify: ___________________________ Water Supply: _____________________________
Number of Bedrooms: _______________________ Site Contain Wetlands: ______________________
Basement: ________________________________ Existing Wells Present: ______________________
Basement Fixtures: _________________________ Existing Easements Present: _________________
Number of People/Employees: ________________ Domestic Wastewater Only: __________________
Number of Shifts: __________________________ Property subject to other agencies: ____________
Number of Seats: __________________________ If so, who: ________________________________
Number of Toilets/Urinals: ___________________
TOTAL APPLICATION FEE: _________________
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.
_____________________________________________ ___________________________________________
Signature of property owner/legal representative* Date
*You must provide documentation to support claim as owner’s legal representative.
Existing easements present
Property subject to other agencies
click to sign
signature
click to edit
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