Bladen County Health Department
Application For Environmental Health Services

Land Owner: Phone:
Mailing Address:
911 Address:
City: State/Zip:
       
Occupant: Phone:
Mailing Address:    
911 Address:    
City: State/Zip:
       
Tax Account #: Quad/PIN#:
Subdivision/MHP: State Rd:
       
Directions:

The owner of the property described hereby applies to Bladen County Health Department for:

Water Sample (Bacteria) $25.00
Water Sample (Chemical) $25.00
Water Sample (Nitrate/Nitrite) $25.00
Water Sample (Petroleum) $40.00
Water Sample (Pesticide) $35.00
Existing Septic System Approval $30.00
Septic System Repair Permit $
Improvement Permit (_____/Revision_____ ) $75.00
Improvement Permit Only $25.00
Construction Authorization-Operation Permit $50.00
  **TOTAL AMOUNT** $

Proposed Facility/Structure:

Total # of Bedrooms: Total # of People:
Mobile Home Size:    
Owner:
Address of Owner:
       
Business/Type: # Employees:
# Shifts:    
Other (Type/Usage):
Type of Water Supply:
County Individual Well-New
Community Individual Well-Existing
An Asterisk will denote if applicable:
The property contains previously identified jurisdictional wetlands.
Wastewater other than sewage will be generated.
The site is subject to approval by other public agencies.
       
Type Wastewater System Preferred:
  Conventional   Modified Conventional
  Alternative   Experimental / Innovative
  Any - Describe
 

Include with this application:
A surveyor's plat or site plan of the property line locations and measurements;
Proposed and existing facilites structures
Existing wells, water lines, power lines and any other pertinent information

Plat: Provided?     Date: Plat:
Site Plan: Provided?     Date    

The undersigned person agrees that they have read the foregoing application and that the contents of same are true. It is understood that any permit applied for herein shall be void and of no effect if any of the above facts are not true. This form is an application only and is not intended to be a permit for the installation, alteration or repair of a sewage disposal system. the Bladen County Health Department does not guarantee that this sewage system will function in a satisfactory manner and assumes no liability for damages caused by the malfunction of this system.

Date: __________________ Applicant's Signature __________________________________________

 

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Copyright © 1999 Public Health Grant
Last modified: September 20, 2007