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2. The intent of this application is to provide information in addition to the plans regarding the operational procedures of the facility.
4. The Rules Governing the Sanitation of Residential Care Facilities (15A NCAC 18A .1600) requires plans and specifications for new construction or modification of residential care facilities, except family foster homes, shall be submitted to the Richmond County Health Department for review and approval. Plans must be submitted with the necessary paperwork (see following checklist) to the Richmond County Health Department.
8. Submittal Checklist

   1. Plans Drawn to Scale for Residential Care Facility
   2. Completed Application
10. Establishment Plans
    Upload Establishment Plans
14. Establishment Name
16. Owner of Facility
18. Supervising Agency (If Applicable)
20. Supervising Agency Contact Phone Number
22. Contact Person Information
24. Facility Address
26. Day Phone Number
28. Other Phone Number
32. Proposed Opening Date
    Proposed Opening Date
34. License Number (If Applicable) Maximum Capacity
36. What dates/times will someone be on-site at the facility?
40. Sewage Disposal

    1. Municipal
    2. Septic System
42. Water Supply

    1. Municipal
    2. Private Well
46. Acknowledgement*

    I hereby certify that the information in this application is correct, and I understand that any deviation without prior approval from this Health Regulatory Office may nullify plan approval.

    1. I understand.
48. 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.

    1. I agree.
50. Electronic Signature*
52. Date*
    Date
Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit

* indicates a required field