Page 1 of 2 Application Checklist

Application Checklist for the following types of applications: • Septic System Improvement Permit (Evaluate and Permit New Septic System, or Expand/Relocate current Septic System)• Septic System Construction Authorization (Permit to Install a New, Expansion or Relocation of a Septic System)• Septic System Repair Permit (Current Septic System is not working and needs repair/replacement)• Reuse of Existing Septic System or Well (Compliance Permit for an Addition to property or Change of use)• Well Permit (Permit to install/repair a drinking water well)

All documentation must be submitted at time of application and uploaded to https://www.nhcgov.com/coast/.

☐YES I have completed and signed the Application for On-Site Water Protection Program (OSWP) Septic and/or Well.

☐YES ☐ N/A Signature of the owner or owner's legal representative document (only if applicant is not the owner).

☐YES Provided a site plan, survey or plat of the property, drawn to scale, between 1” = 10’ and 1” = 60’ Please show all of the following that are applicable to your property:

• Property dimensions and boundaries• All easements (utility, drainage, access, etc.)• All existing and proposed facilities, structures, and additions• Any other appurtenances (including: driveways, walkways, sheds, decks, porches,

steps/landings, swimming pool, underground storage tanks, etc.)• Surface waters, ponds, streams, ditches, swales, creeks, marshes, wetlands, storm water

areas, mean high water lines, CAMA setbacks, etc.• Existing septic system; show setbacks to property lines and other fixed reference points;• All wells within 50-100’ of the property lines• All plumbing connections to sewer and water• All topography lines• Include north arrow

*Additional information may be needed if it is not provided on the site plan or survey.

☐YES ☐ N/A A copy of the deed or recorded plat or subdivision plan: showing date recorded; and any previousdeeds that show subdivision of the property (Not required for replacement well).

☐YES ☐ N/A Completed Homeowner Interview form (required only for Septic System Repair Permit).

☐YES ☐ N/A Written documentation from the nearest provider of sewer and/or water (CFPUA or AQUA) statingthat public sewer and/or public water is Not available to the property. (Without this documentation the application cannot be processed.)

Page 2 of 2 Application Checklist

☐YES ☐N/A A map from the nearest public sewer provider (CFPUA or AQUA) showing location of existing and/orproposed sewer mains, manholes, and lift stations. Any sewer easements on or within 100’ of the subject property must be shown (Required for Well Permits).

☐YES ☐N/A Please provide water bills or metered well readings from the last six month (if requested).

☐YES ☐N/A A utility locator service has been contacted and has/or will locate all underground public utilities onthe following date: ________________________________ (Only applies to Septic System Repairs, Expansion or Replacement of Septic Systems, and Re-use of a septic system).

☐YES ☐N/A The property must be accessible. Property corners, boundaries and easements must be clearly identified/marked at the property location. (Environmental Health Services has flags available).

☐YES ☐N/A Proposed addition(s) to the property must be flagged or staked in their exact location on the site (Environmental Health Services has flags available).

☐YES ☐N/A If applicant desires to re-use the existing septic tank, it must be exposed for inspection. Expose the top of the tank to the invert of the inlet and outlet of the tank (approx. 9-12” around). If tank is not stamped, verification of liquid volume of the tank may be needed.

☐YES ☐N/A All well heads underground must be exposed to verify location(s).

☐YES ☐N/A If applicable, Approved or permitted storm water plans for subdivisions and commercial developmentsis required prior to issuance of a Septic Construction Authorization only.

Please be advised, that If any of the above field items is not complete prior to the site visit by the Environmental Health Specialist, a revisit fee of $70.00 will be assessed and you will be notified as to which field items are not completed.

I, ___________________________________ certify that I have fulfilled the above-referenced application (Print full name of applicant/owner) requirements and the property is prepared for a site evaluation.

_________________________________________________________ ___________________ (Signature of applicant/owner) (Date)

Please note that a separate fee for the Septic Construction Authorization (CA) permit will be required at time of issuance. The fee will be based on the septic system type.