COUNTY OF RANDOLPH
Health Department
204 E Academy St - Asheboro NC 27203
LOCAL TELEPHONE NUMBERS
Asheboro: (336) 318-6262 ● Archdale/Trinity: (336) 819-3262
http://www.randolphcountync.gov
Application for Authorization to Connect Permit (EHSA 1) Rev. 9/5/2019
APPLICATION FOR AUTHORIZATION TO CONNECT PERMIT
If the information in the application for an Authorization to Connect Permit is falsified, changed or the
site is altered, then the Authorization to Connect shall become INVALID. The permit is valid for 12 months
from date of issuance.
Applicant: ________________________________ Date: ____________________________________
Address: __________________________________ Application #: ______________________________
City, ST ZIP _______________________________ Parcel number: ____________________________
Owner: __________________________________ Contact name: ____________________________
Address: _________________________________ Contact phone: ____________________________
City, ST ZIP ______________________________ Contact e-mail: ____________________________
LOCATION INFORMATION:
Location: ________________________________________________________________________________
Subdivision: ______________________________ Lot number: ______________________________
FACILITY INFORMATION:
Is Property Vacant: _________________________ Basement: _______________________________
Existing Structures: _________________________ Basement Fixtures: _________________________
Proposed Use: ____________________________ Proposed Future Structures: _________________
If Other, Specify: ___________________________ Future Structure Type: ______________________
Structure Dimensions: ______________________ Existing System Type: ______________________
Existing Number of Bedrooms: ________________ If Other, Specify: ___________________________
Proposed Number of Bedrooms: ______________ Existing System Location: ___________________
Existing Number of People: __________________ Existing System Age (Years): _________________
Proposed Number of People: _________________
TOTAL APPLICATION FEE: _________________
COMMENTS: ____________________________________________________________________________
________________________________________________________________________________________
AUTHORIZATION TO PROCEED:
I have read this application and certify that the information provided herein is true, complete and correct.
Authorized County and State officials are granted right of entry to conduct necessary inspections to determine
compliance with applicable laws and rules. I understand that I am solely responsible for the proper identification
and labeling of all property lines and corners and making the site accessible so that a complete site evaluation
can be performed.
__________________________________________ _____________________________________________
Signature of property owner/legal representative* Date
*You must provide documentation to support claim as owner’s legal representative.
Proposed future structures
click to sign
signature
click to edit
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