EH_Septic System Application_Common Form_SL2022-11County: _______________________
IMPROVEMENT PERMIT FOR G.S. 130A-335(a2)/SL2022-11
PIN/Lot Identifier: _________________________________________________________________________________________________________
Issued To: _______________________________________________________________________________________________________________
Property Location: ________________________________________________________________________________________________________
Subdivision: _____________________________________________ Lot #: _______ Block: ________ Section: ____
LSS Report Provided: Yes No
If yes, name and license number of LSS: _______________________________________________________________________________________
New Repair Expansion System Relocation
Proposed Structure: ______________________________________________________________________________________________________
Proposed Wastewater System Type: __________________________________ (Initial) _____________________________________ (Repair)
Fill System: Yes No If yes, specify: New Existing (when adding more than 6 inches of fill to system area please provide a fill plan)
Proposed Design Daily Flow: ____________ GPD Proposed LTAR (Initial): __________ Proposed LTAR (Repair): _____________
Design Wastewater Strength: domestic high strength industrial process
Number of bedrooms: _______ Number of Occupants: ______ Other: _______________________________________________________________
Pump Required: Yes No May be required based upon final location and elevations of facilities
Artificial Drainage Required: Yes No If yes, please specify details: ___________________________________________________________
Type of Water Supply: Private well Public well Municipal Supply Spring Other: ____________________________________
Drainfield location meets requirements of Rule .1945: Yes No
Drainfield location meets requirements of Rule .1950: Yes No
Permit valid for: Five years [site plan submitted pursuant to GS 130A-334(13a)] No expiration [plat submitted pursuant to GS 130A-334(7a)]
Permit conditions:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Licensed Soil Scientist Print Name: ___________________________________________________________
Licensed Soil Scientist Signature: ____________________________________________________________ Date: __________________________
The LSS evaluation is being submitted pursuant to and meets the requirements of G.S. 130A-335(a2).
*See attached site sketch*
OWNER ACKNOWLEDGMENT FOR IMPROVEMENT PERMIT ISSUANCE UNDER G.S. 130A-335(a2)(a3)/SL2022-11
Owner or Owner's legal representative Print Name:___________________________________________________________
________________________________________________Owner or Owner's legal representative Signature:Date: __________________________
The LSS/LG evaluation(s) attached to this application is to be used to issue an Improvement Permit in accordance with
G.S. 130A-335(a2) and (a3).
County: _______________________
This Section for Local Health Department Use Only
Initial submittal received: _____________________ by _________
Date Initials
Permit Number: __________________________________________
G.S. 130A-335(a4) states the following: ‘If a local health department fails to act on an application for an improvement permit
submitted pursuant to subsection (a3) of the section within 10 business days of receipt of a complete application, the local health
department shall issue the improvement permit.’
In accordance with G.S. 130A-335(a3) the improvement permit application is:
Incomplete (If box is checked, information in this section is required.)
The following items are missing:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Copies of this were sent to the LSS and the Owner on ____________________
Date
State Authorized Agent: _________________________________________________________ Date: _________________
Denied (See attached report.)
Copies of this were sent to the LSS and the Owner on ____________________
Date
State Authorized Agent: _________________________________________________________ Date: _________________
Complete
State Authorized Agent: __________________________________________________ Date of Issuance: _________________
This Improvement Permit is issued pursuant to G.S. 130A-335 (a2), (a3), and (a4) using the signed and sealed LSS/LG evaluation(s)
attached here. The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The
permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. This site is subject to
revocation if the site plan, plat, or the intended use changes, or if information submitted in the application was falsified,
inaccurate or misleading. The Improvement Permit shall not be affected by a change in ownership of the site. This permit is
subject to compliance with the provisions of the Laws and Rules for Sewage Treatment and Disposal and to conditions of this
permit. The location and identification of all property lines, easements, water lines, and other appropriate utilities shall be the
responsibility of the owner.
The Department, the Department's authorized agents, and the local health departments shall be discharged and released from
any liabilities, duties, and responsibilities imposed by statute or in common law from any claim arising out of or attributed to
evaluations, submittals, or actions from a licensed soil scientist or licensed geologist pursuant to GS 130A-335(a2).
Improvement Permit Expiration Date: ___________________________
*See attached site sketch*
County: _______________________
CONSTRUCTION AUTHORIZATION FOR G.S. 130A-335(a2)/SL2022-11
PIN/Lot Identifier: _________________________________________________________________________________________________________
Issued To: _______________________________________________________________________________________________________________
Property Location: ________________________________________________________________________________________________________
AOWE/PE Plans/Evaluations Provided: Yes No If yes, name and license number of AOWE/PE: ____________________________________
Facility Type: _____________________________________________________________________________________________________________
New Expansion Repair System Relocation
Basement? Yes No Basement Fixtures? Yes No
Type of Wastewater System** ____________________________________ (Initial) ______________________________________ (Repair)
Design Daily Flow: _______________ GPD Wastewater Strength: domestic high strength industrial process
Session Law 2014-120 Section 53, Engineering Design Utilizing Low-flow Fixtures and Low-flow Technologies? Yes No
Installation Requirements/Conditions
Septic Tank Size: __________ gallons Total Trench/Bed Length: ________ feet Trench/Bed Spacing: _____ feet on center
Drainfield square footage: _________________ Trench/Bed Width: ________ inches LTAR: ______________ gpd/ft2
Soil Cover: _____ inches Slope Adjusted Maximum Trench/Bed Depth: ____________ inches
Aggregate Depth: ______inches above pipe ______inches below pipe ______inches total
Pump Tank Size (if applicable): __________ gallons Requires more than 1 pump? Yes No
Pump Requirements: ______ ft. TDH vs. ______ GPM Grease Trap Size (if applicable): __________ gallons
Distribution Method: Serial D-Box or Parallel Pressure Manifold(s) LPP Other:_________________________________
Artificial Drainage Required: Yes No If yes, please specify details: ___________________________________________________________
Legal Agreements (If the answer is “Yes” to any type of legal agreements, please attach a copy of the agreement.)
Multi-party Agreement Required [.1937(h)]: Yes No
Easement, Right-of-Way, or Encroachment Agreement Required [.1938(j)]: Yes No
Declaration of Restrictive Covenants: Yes No
Pre-Construction Conference Required: Yes No
Conditions: ______________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
The construction and installation requirements of Rules .1950, .1952, .1954, .1955, .1956, .1957, .1958, and .1959 are incorporated by reference
into this permit and shall be met. Systems shall be installed in accordance with the attached system layout.
AOWE/PE Print Name: ____________________________________________________
AOWE/PE Signature: ______________________________________________________ Date: ____________________________
This AOWE/PE submittal is pursuant to and meets the requirements of G.S. 130A-335(a2) and (a5).
*See attached site sketch*
**If applicable:
I understand the system type specified is different from the type specified on the application. I accept the specifications of this permit.
Owner/Legal Representative Print Name: __________________________________________________
Owner/Legal Representative Signature: ____________________________________________________ Date: ________________________________________
OWNER ACKNOWLEDGMENT FOR CONSTRUCTION AUTHORIZATION ISSUANCE UNDER G.S. 130A-335(a2)(a3)/SL2022-11
Owner or Owner's legal representative Print Name:
Owner or Owner's legal representative Signature:
___________________________________________________
_______________________________________________Date: _________________
The plans or evaluations attached to this application are to be used to issue a Construction Authorization in
accordance with G.S. 130A-335(a2), (a5) and (a6).
County: _______________________
This Section for Local Health Department Use Only
Initial submittal received: _____________________ by _________
Date Initials
Permit Number: ___________________________________________
G.S. 130A-335(a6) states the following: ‘If a local health department fails to act on an application for a construction authorization
submitted pursuant to subsection (a5) of the section within 10 business days of receipt of a complete application, the local health
department shall issue the construction authorization.’
In accordance with G.S. 130A-335(a5) the construction authorization application is:
Incomplete (If box is checked, information in this section is required.)
The following items are missing: _________________________________________________________________________________
____________________________________________________________________________________________________________
Copies of this were sent to the AOWE/PE and the Owner on ____________________
Date
State Authorized Agent: ________________________________________________________ Date: _____________________
Denied (See attached report.)
Copies of this were sent to the AOWE/PE and the Owner on ____________________
Date
State Authorized Agent: _________________________________________________________ Date: _____________________
Complete
State Authorized Agent: _____________________________________________________ Date of Issuance: _________________
This Construction Authorization is issued pursuant to G.S. 130A-335(a2), (a5), and (a6) using the signed and sealed plans or
evaluations attached here. This Construction Authorization is subject to revocation if the site plan, plat, or the intended use
changes, or if information submitted in the application was falsified, inaccurate or misleading. The Construction Authorization
shall not be affected by a change in ownership of the site. This Construction Authorization is subject to compliance with the
provisions of the Laws and Rules for Sewage Treatment and Disposal and to the conditions of this permit. The location and
identification of all property lines, easements, water lines, and other appropriate utilities shall be the responsibility of the owner.
Final landscaping shall be constructed to divert water and establish vegetative cover.
The Department, the Department's authorized agents, and the local health departments shall be discharged and released from
any liabilities, duties, and responsibilities imposed by statute or in common law from any claim arising out of or attributed to
plans, evaluations, preconstruction conference findings, submittals, or actions from a person licensed pursuant to Chapter 89C of
the General Statutes as a licensed engineer or a person certified pursuant to Article 5 of Chapter 90A of the General Statutes as an
Authorized On-Site Wastewater Evaluator in GS 130A-335(a2), (a5), and (a7). The Department, the Department's authorized
agents, and the local health departments shall be responsible and bear liability for their actions and evaluations and other
obligations under State law or rule, including the issuance of the operations permit pursuant to GS 130A-337.
Construction Authorization Expiration Date: ___________________________
*See attached site sketch*