Septic-Well-Permit-Application - 7-28-2023_v1Page 1 of 2 Application
Application for On-Site Water Protection Program (OSWP) Septic and/or Well
Application Type (check all that apply):
Septic System Improvement Permit (IP) Evaluate/permit septic
system: New Relocation Expansion
Construction Authorization (CA) Permit to install septic system
Septic System Repair Permit Septic system is not working
Permit Revision (CA/IP) Permit #
Re-Use of Existing System: Septic Well
Well Permit drinking water well:
New Replacement/New Repair Abandonment
Water Sample: Bacteria Inorganic Organic
Soil Wetness Monitoring alternative to determine soil wetness
Building Safety Permit #: (if applicable)
Applicant Information: Owner Information: Same as Applicant
Applicant Name:
Mailing Address:
City,State,Zip:
Cell / Home Phone:
Work Phone:
Email Address:
Property Owner:
Mailing Address:
City,State,Zip:
Cell / Home Phone:
Work Phone:
Email Address:
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Property Information:
Tax Parcel # _ Date originally deeded & recorded:
Property Address: City,Zip:
Subdivision Name: Section/Phase: Lot #:
Lot Size (total acres): Acreage to be evaluated (IP only): less than 1 acre greater than 1 acre
County Sewer: Yes No If yes, sewer provider: CFPUA AQUA Other:
Water Supply: New Well Existing Well Community Well Shared Well Public Water Spring
If public water, water provider: CFPUA AQUA Other: Is there an existing irrigation well? Yes No
# occupants/employees drinking water well will serve: # homes/ buildings drinking water well will serve:
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Development Information: (check any that apply) Residential Non-Residential/Commercial/Industrial
New Septic System
Building Addition/Conversion: Relocation of Existing Septic System Expansion of Existing Septic System
Building Addition/Conversion, Re-Use Existing System: Septic System Private Drinking Water Well
Repair to Malfunctioning Septic System (septic system not working)
Mobile Home Replacement
Adding a Swimming Pool (Private)
Page 2 of 2 Application
Residential Specifications: New Construction Existing Construction
Type of Residence: Single Family Home Multi-family/Duplex Mobile Home Other:
Existing number of bedrooms: Maximum number of occupants (# bedrooms x 2):
Are you adding bedrooms? YES NO Will there be a basement? YES NO
Proposed total number of bedrooms: Plumbing fixtures in Basement YES NO
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Non-Residential Specifications:
Type of business: Industrial Commercial
Total square footage of building(s): Maximum number of employees: Maximum number of seats:
Additional Information to help determine design daily flow of sewage:
Type of water using fixtures:
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If applying for Septic System Construction Authorization(CA) or Septic System Repair:
Please indicate desired Septic System Type(s): (Systems can be ranked in order of your preference.)
Any _ Conventional _ Accepted _ Alternative _ Innovative _ Other _____
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The Applicant shall notify the local health department upon submittal of this application if any of the following apply to the property in
question. If the answer to any question is “yes”, applicant must attach supporting documentation.
Yes No Does the site contain any jurisdictional wetlands?
Yes No Does the site contain any existing wastewater systems?
Yes No Is any wastewater going to be generated on the site other than domestic sewage? Please explain: _
Yes No Are there any easements or right of ways on this property?
Yes No Is the site subject to approval by any other public agency? Please explain:
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If the information submitted in the application for an Improvement Permit, Construction Authorization, Well Permit, or
any of the above application types is found to have been incorrect, falsified or changed, or the site is altered, the Permit
or Construction Authorization shall become invalid, and may be suspended or revoked. It is unaffected by a change in
ownership of the property. The permit is valid for either 60 months or without expiration depending upon documentation
submitted. (Complete site plan = 60 months; complete plat = without expiration).
I hereby certify that I am the applicant/owner, or owner’s authorized legal representative. 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.
The issuance of this permit by New Hanover County Health and Human Services in no way guarantees the issuance of other
required permits. The applicant is responsible for checking with other appropriate governing bodies to assure meeting
their requirements.
_ Property owner’s or owner’s legal representative** signature (required) Date
**Must provide documentation to support claim as owner’s legal representative.
To make application for Environmental Health Services, please provide all information required on the checklist for each permit you are
applying for and upload this application and all supporting documents to New Hanover County COAST at
https://www.nhcgov.com/coast/.