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Local Confinement Plan Review Application

2. The intent of this application is to provide information in addition to the plans regarding the operational procedures of the facility.

   The intent of this application is to provide information in addition to the plans regarding the operational procedures of the facility.

4. The Rules Governing the Sanitation of Local Confinement Facilities (15A NCAC 18A .1500) require that plans be submitted for approval prior to construction, renovation, modification, change of ownership of such facilities by the local Health Department. Plans must be submitted with the necessary paperwork (see following checklist) to the Richmond County Health Department.

   The Rules Governing the Sanitation of Local Confinement Facilities (15A NCAC 18A .1500) require that plans be submitted for approval prior to construction, renovation, modification, change of ownership of such facilities by the local Health Department. Plans must be submitted with the necessary paperwork (see following checklist) to the Richmond County Health Department.

8. Submittal Checklist

   1. Plans and specifications for new construction or modification of Local Confinements shall be submitted to the Richmond County Health Department for review and approval before beginning construction.
   2. Completed Application

10. Establishment Plans

    Upload Establishment Plans

14. Establishment Name

16. Owner of Facility

18. Supervising Agency (If Applicable)

20. Supervising Agency Contact Phone Number (If Applicable)

22. Contact Person Information

24. Facility Address

26. Day Phone Number

28. Other Phone Number

30. Proposed Opening Date
    Proposed Opening Date

32. Sewage Disposal

    1. Municipal
    2. Septic System

34. Water Supply

    1. Municipal
    2. Private Well

38. Acknowledgement*

    I hereby certify that the information in this application is correct, and I understand that any deviation without prior approval from this Health Regulatory Office may nullify plan approval.

    1. I understand.
40. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
42. Electronic Signature*

44. Date*
    Date

Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field