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Step One

Please note: The septic system and any other improvements or conditions shall be installed and maintained as indicated on the permit issued. This permit shall in no way be taken as a guarantee or implied warranty that the septic system will function for any given period of time or that representatives of the Health Department assume any liability for related damages, consequential or direct, which are caused or which may be caused by a malfunctioning of such system.
To complete this application you will need:
12 Digit parcel number for the property. Parcel Number-This number can be obtained from Land Records/Mapping Department 2nd Floor, located at 1401 Fayetteville Road or Amy.fulp@richmondnc.com or 910-410-1139.
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In the absence of the above documentation, the property owner may provide the local health department with documentation that designates a legal representative. A property owner may:
1. Complete this form to document his or her legal representative
2. Provide his or her own form that contains the information in this form
Owners Statement
I, the owner of the property, give the applicant authorization to act as an agent on my behalf in applying for, signing, obtaining any of the documents below.
Documents
1. Application for Improvement Permit (IP)/ Authorization to Construct (CA)
2. Improvement Permit (IP)/ Authorization to Construct (CA)
3. Application for soil-site evaluation
4. Application for Compliance Inspection
5. Application for permits for private drinking well water/well abandonment
I agree to abide by all decisions and/or conditions between the legal representative acting on my behalf and the Richmond County Health Department, Environmental Health Section.
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.
Electronic Signature*
Date*
Date
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Acknowledgement*
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.
1. I understand.
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.
Property Owner's or Owner's Legal Representative Electronic Signature*
Date*
Date

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