Migrant Labor Camp Application (2023)

10 JOHNSTON COUNTY ENVIRONMENTAL HEALTH FOR OFFICE USE ONLY Date Received ______________ Application # _ ______________ Received By ________________ Application for a Migrant Labor Camp 309 East Market Street , Smithfield , NC 27577 Phone 919 - 989 - 5180 Fax 919 - 989 - 5190 Email septicwellapplication @ johnstonncgov Application and Plan Submittal A completed Application and associated Fees must be submitted to the Johnston County Environmental Health Office This application may be submitted in person , by email at the email address given above or by US Mail Once the application is received ; you will be contacted for payment processing which can be completed over the phone with a card , by mail or in person Checks should be made payable to Johnston County The Migrant Labor Camp fee is 5000 If more than one water sample is needed , the applicant will be charged and additional 2850 per sample If this application is incomplete or without payment , the application will be held and the applicant will be notified of any deficiencies APPLICANT INFORMATION Operator Name ______________________________________________________ Phone ____________________________________ Mailing Address ______________________________________________________ Email __________________________________ PROPERTY OWNERS INFORMATION Complete only if different from the Applicant Information Owner's Name _______________________________________________________ Phone ____________________________________ Mailing Address ______________________________________________________ Email _____________________________________ SITE INFORMATION Address of Camp _ _______________________________________________________________________________________________ Directions to Camp from Smithfield _ ________________________________________________________________________________ __ _____________________________________________________________________________________________________________ Is this a new or existing Migrant Labor Camp New Existing If existing , was the camp utilized last year Yes No Type of Housing Unit Mobile Home Barracks Dormitories House Other specify ________________________ Number of Occupants _________ Projected Date of Occupancy _________________ Projected Date of Departure _________________ WATER SUPPLY AND WASTEWATER DISPOSAL Type of Water Supply Public Water Supply Private Well Other specify _ ___________________________ If camp is utilizing a private well water source , is the well available for inspection and collection of a water sample by the Environmental No Health Specialist Yes Type of On - Site Sewage Disposal System Septic System Municipal Sewer Chemical Portable Toilets Privy Other specify ____________________________________ INSPECTION Is the camp ready for inspection Yes No If no , what is the projected date the camp will be ready for inspection __________ I certify that I have carefully read the questions on this application and have answered them completely and truthfully By affixing my signature to this application , I grant permission for a Johnston County Environmental Health Specialist to perform inspections and take water samples at the above cited Migrant Labor Camp If it is determined at any time that I have provided misleading or false information on or in support of this application , I understand that my application may be denied or that my certification may be revoked ________________________________________________________________________________ _______ ______________________________________________________ Owner Operator Signature Date STAFF USE ONLY Assigned County File # _______________________________________ Approved Number of Occupants __________________________ Environmental Health Specialist _ _____________________________________ Inspection Date ________________________________ Water Sample Date ____________________________________ Re - Sample Dates _ __________________________________________Page