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Adult Day Service Facility Plan Review Application

  1. The intent of this application is to provide information in addition to the plans regarding the operational procedures of the facility.
  2. The North Carolina Rules Governing the Sanitation of Adult Day Service Facilities (15A NCAC 18A .3300) 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.
  3. Submittal Checklist
  4. Upload Plans with application
  5. Sewage Disposal
  6. Water Supply
  7. 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.
  8. 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.
  9. Leave This Blank:

  10. This field is not part of the form submission.