Application No. _________
Page 1 of 1
HENDERSON COUNTY
EMERGENCY SERVICES IMPACT REPORT FORM
In accordance with §200A-105, an Emergency Services Impact Report shall be required for subdivisions
proposing one-hundred (100) lots/units or more, or subdivisions proposing more than 50 units located more
than 5 road miles from a fire station and shall be submitted as part of the Master Plan approval.
Subdivision Name: _______________________________________________________________________
Number of Proposed Lots: ________
Fire Insurance District: _________________________________________ (Name or Not Applicable (NA))
1. Distance from Nearest Fire Station: ____________ (Road Miles)
2. Distance from Nearest EMS Station: ___________ (Road Miles)
EMS Station Response Time = ((______ (result from 2)) ÷ 35 mph) × 60 minutes = __________ (Minutes)
Route to EMS Station (Please attach map highlighting the route):
Route Road Names and Classifications (Local, Collector, Thoroughfare, Expressway, Boulevard):
Number
of Passing Posted
Names Classifications Areas Speed Limit(s)
1. __________________ and __________________ and __________ and __________
2. __________________ and __________________ and __________ and __________
3. __________________ and __________________ and __________ and __________
4. __________________ and __________________ and __________ and __________
5. __________________ and __________________ and __________ and __________
(If additional space is needed you may attach additional sheets)
Water resources for fire suppression available: _________ (Y/N)
If Yes:
1. Type of water source (circle one) Static or Pressurized
2. Hydrants:
a. Number: _______
b. Maximum Spacing: _______
3. Capacity: ________
4. Flow Rate: __________________ (Gallons per Minute)
5. Pressures:
a. Static Pressure: ___________
b. Residual Pressure: ____________
Interested in Providing a new Fire or EMS Substation? ___________ (Y/N)
