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Billing Address*

Address*

SIGNATURES REQUIRED:

Use the following question to decide which signature page that is needed to proceed.

Is this application being submitted by the Property Owner or the Property Owner's Authorized Representative?*

Property Owner
Owner's Authorized Representative

DOCUMENTATION OF OWNERSHIP REQUIRED

FORM: Ownership signature

DOCUMENTATION OF AUTHORIZATION TO ACT AS OWNER'S REPRESENTATIVE REQUIRED

FORM: Authorization to Act as Owner's Representative

An upload of the completed, signed form (located at the link above) is required at the end of this application. Other acceptable documents include, without limitation: Power of Attorney documents, etc.

PHOTO RELEASE*

YES
NO

By checking this statement, I grant the Orange County Health Department permission to take drone photographs of the location/property.

By checking this statement, I grant the Orange County Health Department permission to take drone photographs of the location/property.  By electronically/actually signing this document, I grant Drone Video Photography 

LLC full 

permission to take photographs and video a

t

the below locaAon/property.  The photography 

and video will be shot on private property and I have authority to give Drone Video 

Photography LLC permission to shoot photography and video of the locaAon

/property.  

CURRENT OR PLANNED Water Source *

New Well

Existing Well

Community Well

Public Water

Are there any recorded easements or rights-of-way on this property?*

Yes
No

Does this property contain streams, ponds, or floodplains?*

Yes
No

Does this property contain any jurisdictional wetlands?*

Yes
No

Will this parcel contain any stormwater control measures (SCMs)?*

Yes
No
Unknown at this time, but I will submit additional information if this changes.

Is this project subject to approval of another agency (e.g. Planning, U.S. Army Corps of Engineers, etc.)?*

Yes
No

Agency (or Agencies) who must approve this project*

Project Type*

Please select the category that best matches your project. FY22-23 Fee Schedule

New Residential (Single Lot) Septic and/or Well
Residential Subdivision/Recombination
Existing System Authorization
Residential Addition/Remodel (no additional bedrooms)
Residential Septic Repair (no fee)
Residential Expansion
Revision to Application for Residential Permit(s)
Septic System Abandonment (no fee)
Well Repair

Have you consulted a Licensed Soil Scientist?

If you have and you would like to provide a copy of their report, please attach a copy on the final page of this application.

Yes
No

Is this application for a SL2018-114 permit using the report from the Licensed Soil Scientist?*

Yes
No

Please Review the Following Statement:*

The LSS Evaluation attached to this application is to be used to produce design and construction features for permitting in accordance with SL 2018-114 Section 11.(c).

Yes
No

New Residential Permit(s) Requested*

Check all that apply.

New Improvement Permit
New Construction Authorization
New Well Permit (Private Drinking Water or Irrigation)
New Well Permit (Geothermal or Monitoring)

Project Description*

Please describe your project.

Improvement Permit Number (If one has been issued and is still valid)

example: IP20-0500, IP21-0692, etc.

Is this project for a single family or multi-family dwelling?*

Single family
Multi-family

Number of dwelling units *

Number of bedrooms per unit*

Maximum number of occupants per dwelling*

Other preferred system type.

Please check the box if any of the following will be included in the proposed structure:

Project Description*

Please describe your project.

Does the property contain any existing septic systems or water supply wells?*

No
Yes. There is a septic system, and it is in use.
Yes. There is a well, and it is in use.
Yes. There is a septic system, but it is NOT in use.
Yes. There is a well, but it is NOT in use.

New Permits Requested *

Check all that apply. FY22-23 Fee Schedule

NOTE:

An Operation Permit Revision is required for existing systems that have: 1) a previously designated repair area, and 2) the proposed property line does not encroach the designated area.
An Improvement Permit is required for an existing system that does not have a previously designated repair area.

New Improvement Permit(s) for Proposed Lot(s)
Improvement Permit to Designate Repair for an Existing System
New Construction Authorization(s) for Proposed New Lot(s)
New Well Permit(s) for Proposed New Lot(s)
Operation Permit Revision for Existing System

Number of Proposed Lots*

How many permits are you applying for?

Other system type

Project *

Remodeling (interior only)
Addition other than bedroom (e.g. deck, porch, patio, pool, etc.)
Accessory structure(s) without bedroom(s)
Solar panel installation (no fee)
Return an existing septic system to use
Connect a new structure to an existing system
Mobile Home Park new home

Solar installation*

Ground mounted solar array
Rooftop mounted solar array

Project Description*

Please describe your project.

Please describe the problem*

Check all that apply. There are no fees with Septic Repair Permits. Installing a new system or tank where there is no known failure of the system is not a Repair. Please go back to New Improvement Permit and Construction Authorization.

Backing up into home or facility
Septic tank overflowing
Damage to system
Discharge of sewage on the ground
Other (USE THE TEXT BOX BELOW TO DESCRIBE THE PROBLEM(S))

Other problem description

Have you consulted a certified septic installer or inspector?*

Yes
No

Is the problem worse after heavy rain?*

Yes
No

Is the problem worse when clothes are washed?*

Yes
No

Is the problem worse when there are visitors?*

Yes
No

Have you checked for leaking fixtures?*

Yes
No

Do you have water treatment plumbed to the septic tank?*

Yes
No

Has there been any recent work to the property such as digging, tree removal, driving of heavy equipment, etc.?*

Yes
No

Are there any strong cleaners, disinfectants, or medications in use?*

Yes
No

Does your home contain any of the following?*

Check all that apply.

Basement with plumbing
Garbage disposal
Sewage lift station

Is this expansion to add bedroom(s) to an existing dwelling, or is this expansion for bedrooms in a new Accessory Dwelling Unit?*

Additional bedroom(s) in an EXISTING dwelling
Bedroom(s) in a NEW Accessory Dwelling Unit

Will the number of bedrooms in the existing dwelling change?*

No
Yes, it will increase
Yes, it will decrease

Permit Numbers of All Permits for which Revision is Requested*

Example: IP21-0789, CA21-0543, W21-0497

Components to be Abandoned*

Check all that apply.

Septic Tank
Pump Tank

Reason for Abandonment *

Permit Requested*

Please check all that apply.

Repair with bacteria water sample ($75)
Repair with full water sample suite ($175)

Is a well liner needed*

Yes
No
Unknown at this time

If a liner is deemed necessary, a well camera report and additional fee ($100) are required.

Liner Report Upload

Site Preparation Verification*

Please verify each site preparation is complete by checking the box below. Signature below certifies that the site is prepared.

Contact information is correct
Vegetation has been thinned to permit access
Property lines and property corners have been marked on site
All proposed structures and appurtenances have been marked on site
All stream, flood plain, and/or wetland buffers (if present) have been marked on site

NOTE:

Failure to prepare the site may cause long delays in permitting, may result in a Notice of Incomplete Application, and/or result in a $50 re-inspection fee.

Meeting on site is not a substitution for having the site properly prepared.

Markings and Site Preparation Completed by:*

Owner
Owner's Representative/Applicant
Registered Land Surveyor
Other Consultant

ABOUT PLANNING APPROVAL

FORM: Planning Approval outside of the County Jurisdiction

A Zoning Report is required of all NEW applications for Improvement Permits and Construction Authorizations; all Existing System Authorizations where the change of use includes building outside of the footprint; and MOST applications for expansions of existing systems.

Zoning Reports are honored for up to 12 months without new approval.

Parcels in the Towns of Chapel Hill, Carrboro, and Hillsborough must complete the linked document with their Planning offices.

Acknowledgement

This application has been signed by the current OWNER of the property or the OWNER'S LEGAL REPRESENTATIVE (documentation required) who has entered into a contract or lease with the owner and who may legally represent the property OWNER in the transactions regarding the property. I, the undersigned, am the property OWNER or the OWNER'S LEGAL REPRESENTATIVE. By signing this application, I grant the Orange County Health Department, Environmental Health Division, right of entry to the property to perform the service(s) requested.

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