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2. The intent of this application is to provide information in addition to the plans regarding the operational procedures of the facility.
4. 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.
8. Submittal Checklist

   1. Plans drawn to scale and specifications for new adult day service facilities shall be submitted to the Richmond County Health Department for review and approval prior to initiating construction
   2. Completed Application
10. Establishment Plans
    Upload Plans with application
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. Phone Number (Day)
28. Phone Number (Other)
30. Proposed Opening Date
    Proposed Opening Date
32. License Number (If Applicable) Maximum Capacity
34. What Dates/Times Someone Will Be On-Site at the Facility
36. Sewage Disposal

    1. Municipal
    2. Septic System
38. Water Supply

    1. Municipal
    2. Private Well
42. 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.
44. 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.
46. Electronic Signature*
48. Date*
    Date
Leave This Blank:


50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit

* indicates a required field