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3. Applicant/Owner Information
5. Owner of Property
7. Address
9. Email Address
11. Phone Number
13. Cell Phone Number
15. Directions to Property
19. Site Information
21. PIN
23. Subdivision
25. Lot Number
27. Wastewater Disposal

    1. Proposed
    2. Existing
    3. Public Sewer
29. Name on Permit (Proposed)
31. Year of Record Card for Existing
35. Type of Facility

    1. Residential
    2. Commercial
    3. Farm
    4. Restaurant
    5. Church
39. Number of Users
41. Number of Homes
45. Existing Well Locations
    List any existing water supplies on the property.
49. Check all of the following that apply:

    1. Are there any easements or right of ways on this property?
    2. Are there any surface waters or designated wetlands on this property?
    3. Are there any well variances associated with this property?
    4. Are there any known underground contaminates on this property?
    5. Are there any known landfills, waste storage, graves (animal or human), burial pits, trash pits, hog lots, feed lots, on this property or within 100 feet of this property?
    6. Are there any spray fields for fertilizer, pesticides, or liquid waster application on this property or within 100 feet of this property?
    7. Are there any under ground storage tanks on this property or within 100 feet of this property?
53. The issuance of a Well Construction Authorization Permit by the Health Department in no way guarantees sufficient yield or potable water. It merely shows potential sources of contamination and setback requirements.
55. The Permit is subject to revocation if the site plan or intended use changes.
57. It is the responsibility of the owner or requester to disclose information on all potential sources of contamination. The Environmental Health Specialist or the Richmond County Health Department does not assume liability for unknown or undisclosed sources of contamination.
59. The fee is NON-REFUNDABLE once the property is visited by an Environmental Health Specialist.
63. Upload Site Plan Drawing
    Submit this application accompanied by a site plan drawn to scale for all new and monitoring wells. Existing homes can use a copy of Richmond County Health Departments record card for a site drawing. Update all information on the copy before returning with the application. All property corners must be staked. All undergrowth must be cleared to the point that the property can accessed to be evaluated.
67. 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.
69. Electronic Signature*
71. Date*
    Date
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73. 1. Receive an email copy of this form.
74. Email address

    This field is not part of the form submission.

75. Submit

* indicates a required field