Sample Forms, Letters and Publications

On-Site Wastewater Forms

Maintenance and Inspection Forms

• Groundwater Report Form (PDF)
• Inspection of Engineered Systems (PDF)
• Inspection of Wastewater Treatment Plant (PDF)
• LPP Inspection Report Form (PDF)
• LPP Monitoring Visit Guide (PDF)
• O&M Service Provider Checklists
• Pre-occupancy Report - Migrant Housing (XLS)
• Pump Tank Operation Permit Checklist
• Subsurface System Inspection Form (DOC)
• Subsurface Wastewater Monitoring Form (XLS)
• Tank Yard Inspection Form (PDF)

Generic Forms/Permits

• North Carolina Distribution Encroachment Agreement for Dispersal Field Encroachments - 03/25/2024
  • Example A (DOCX)
  • Example B (DOCX)
  • Example C (DOCX)
• Operation Permit Inspection Checklist (DOC)
• Records Retention Schedule for Health Departments
• Request or Decline Revised AC (DOCX)
• Sample Maintenance and Inspection Agreement (PDF)
• Site Plan Worksheet (DOC)
• Site Sketch IP CA (DOC)
• Voluntary Relinquishment of Administrative Appeal Rights (DOCX) - 04/01/2024

Private Wells Forms

• Variance Request Form for 2C .0100 and .0300 Fillable (PDF)
• Inspection Checklist for Private Wells (PDF)
• Variance Request Form for 2C .0100 Well Construction Standards (PDF)
• Well COC (DOC)
• Well Permit Application Denial Letter (DOC)