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Landowner:___________________________________________________________Phone:______________________________ Address:____________________________________________________City:______________________Zip________________ Quad/Pin:___________________911 Address:______________________________________ Tax Account:_________________ Directions: _______________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Occupant:_____________________________________________________________Phone:__________________________ Address:____________________________________________________City:______________________Zip________________ |
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The Owner of the property described hereby applies to Bladen County Health Department for: |
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● Septic System Repair Permit $ No Charge ___ ● Water Sample (Bacteria, Chemical or Nitrate) 25.00 ___ ● Complete Well Water Testing Kit 55.00 ___ ● Water Sample (Pesticide) 35.00 ___ ● Water Sample (Petroleum) 40.00 ___ ● Existing Septic System Approval 75.00 ___ ● Improvement Permit Only-- Perk Test (600 gpd or less) 75.00 ___ ● Construction Authorization Only (600 gpd or less) 75.00 ___ ● Full IP (Improvement Permit—Operation Permit) (600 gpd or less) 150.00 ___ o 601 to 1250 gpd 250.00 ___ 1251 to 3000 gpd 400.00 ___ ● Revision of CA or Expansion (addition of bedroom (s)) 100.00 ___ ● Food Establishment Plan Review 100.00 ___ ● Well Permit with NEW paid full IP 150.00 ___ ● Well Permit without full IP 200.00 ___ ● Tattoo Parlor 250.00 ___
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Residential Specifications Proposed Facility/Structure Type::___________________________________ Mobile Home: _____x____ Mod: ______________ Bedrooms: ___________People: ___________Type Water Supply______________________________ Wetlands: ____________ Wastewater System Preferred: ____________________________ Repair: _________________________ Other: ______________ Commercial/Industrial Specifications Type of Facility: _________________________________ Number of Employees: ___________________ Shifts: _____________ Type Water Supply: ______________________Wetlands : _______________Wastewater System Preferred: _________________ Repair:______________________ Other:_______________________________________________________________________
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A survey map and site plan of the property line locations and measurements; proposed and existing facilities/structures, wells, water lines, power lines and any pertinent information must be included with this application. The undersigned person agrees that he/she has read the foregoing application and that the contents of same are true. It is understood that any permit applied for herein shall be void if any of the above facts are not true. This form is an application only and is not intended to be a permit for the installation, alteration or repair of a sewage disposal system. The Bladen County Health Department does not guarantee that this sewage system will function in a satisfactory manner and assumes no liability for damages caused by the malfunction of this system. |
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Date: __________________________ Applicants Signature: ________________________________________________________ Received By: ___________________ Check # __________________ Cash: ______________ Date Paid: ____________________ |