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Well Construction Application (New, Repairs)

  1. Applicant/Owner Information

  2. Site Information

  3. Wastewater Disposal

  4. Type of Facility

  5. List any existing water supplies on the property.

  6. Check all of the following that apply:

  7. 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.

  8. The Permit is subject to revocation if the site plan or intended use changes.

  9. 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.

  10. The fee is NON-REFUNDABLE once the property is visited by an Environmental Health Specialist.

  11. 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.

  12. 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.

  13. Leave This Blank:

  14. This field is not part of the form submission.