Form Center

Step One

Please select the type of application you will be completing:*
1. Existing System Release Application
2. Existing System Re-Use Application
3. Improvement Permit Application
4. Repair Application
You may select more than one option.
Please describe the septic issues you are having.*
How long have your septic system problems been occurring?
Has a plumber or septic tank contractor evaluated your septic system?
Please provide the report:
How many individuals live in the home?
Do you have any leaks?
This includes any dripping fixtures or toilets that "hang."
Is wastewater surfacing in the yard?
Do you have backups in the house from the toilet, bathtub, or sink?
Do the problems only happen after heavy rains?
Has the septic tank been pumped recently?
Date it was pumped:
Date it was pumped:
Are you the property owner?*
On-Site Owner Consent Form*
On-site owner consent form can be found here.
Continue

Will the property be on Municipal Water or Well Water?*
Please list water supplier:*
Will the property utilize private well?
Is the well existing?
Original date the property was created by recorded deed description/recorded plat:
Original date the property was created by recorded deed description/recorded plat:
Do you know if the property contains any previously identified jurisdictional wetlands?
Will any wastewater other than domestic sewage be generated on the property?
Please explain:*
wastewater generated from other than human sanitary uses including, but not limited to: industrial uses (chemicals, pesticides, paints), food processing (excessive grease/oils), commercial uses (beauty salon, taxidermy, furniture refinishing)
Do you know if the property is subject to approval by other local, state, or federal agencies?
Is the property subjected to any legal agreements?
Continue |Go Back

Please select one of the following and provide information for Type of Use for the property:*
Type of Home:*
Size of Mobile Home:
e.g. 14 x 76
Existing # of Bedrooms
Proposed # of Bedrooms
Maximum # of Occupants:
# of Bedrooms:
Type of Construction:*
Please indicate what you are building. Will only apply if "Existing System Release Application" was checked at the beginning of this form.
Please indicate what you are building to include size, bedroom, and type of use.*
Type of Business:
Hours/Days of Operation:
# of Employees:
Will the structure have foundation/floor drains?
Capacity:
How many days of the week will service be held?
Will the facility have a fellowship hall?
Will there be a fully equipped kitchen?
Will the kitchen have an ice machine?
Will the facility have a For Profit Daycare?
# of Children:
# of Employees
Hours/Days of Operation:
Maximum # of Guests:
# of Employees
Hours/Days of Operation:
Will the facility have a fully equipped kitchen?
Will the facility have an ice machine?
Please provide details*
Is this for a Mobile Home Park?
Will only apply if "Existing System Re-Use Application" was selected at the beginning of the form.
Please list Mobile Home Park:
Continue |Go Back

A site plan must be submitted with this application. The site plan must show:
✔ Proposed Dwelling
✔ Property Lines (Side & Road Frontage)
✔ Well Location (if applicable)
✔ Additional Buildings (if applicable)
Site Plan:
Initials:*
I acknowledge that my site plan must meet Planning and Zoning requirements and their Department reserve the right to deny my site plan and put a hold on my application.
Continue |Go Back

By signing below, I acknowledge and understand that any information I submit to Pitt County Environmental Health is considered public information and may be released in a public record request. I certify that all information is true and correct to the best of my knowledge.
Signature:*
Please print full name.
Date:*
Date:
Application #:
Date of Request:
Date of Request:
Fee Paid

Leave This Blank: