Subdivision Application

10 JOHNSTON COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 309 East Market Street , Smithfield , NC 27577 Phone 919 - 989 - 5180 Fax 919 - 989 - 5190 Application and Plan Submittal The completed application , fee , three 3 folded 18x24 or larger copies of subdivision plans , the subdivision evaluation checklist and owners consent form when required shall be submitted to the Johnston County Environmental Health Office The application packet may be submitted in person , by email , by US Mail , FedEx , UPS or another mail or courier service If the application is incomplete , the entire package will be returned with a list of deficiencies APPLICANT INFORMATION Subdivision Name _ __________________________________________________ Date Submitted ____________________________ Property Owner Name _________________________________________________________________________________________ Phone _________________________________ Email _______________________________________________________________ Developer Name _____________________________________________________________________________________________ Phone _________________________________ Email _______________________________________________________________ Surveyor Engineer ____________________________________________________________________________________________ Phone _________________________________ Email _______________________________________________________________ SITE DATA Location ____________________________________________________________________________________________________ State Road & Number , Township Tax ID __________________________________Total Acreage ____________________Number of Lots ______________________ List the Lots to be Evaluated ____________________________________________________________________________________ County City Minimum Building Setbacks Front - _____________________Ft Side - _____________________Ft Rear - _____________________Ft Other Setbacks ________________________________________________________________________________________________________Are Open Space , Wetlands & Buffer Areas Delineated ________________________________________________________________ Intended Use Single Family Dwellings , Number of Bedrooms __________ Other - Explain _____________________ Type of Water Supply ___________________________ On - site Sewage Disposal Systems ________________________________ SUBMITTAL REQUIREMENTS 1 Completed Application and Subdivision Evaluation Checklist2 Fee Number of Lots x 100 per Lot 3 Three 3 folded 18x24 or larger copies of the Preliminary Plat with meters & bounds , parcel area , location of proposed homesite 4 Owners Consent Form when required 5 Soils report from LSS , if available6 Submit any preliminary soil site plans to assist in the evaluation7 Stormwater Statement All owners agents of the property to be considered for this application must sign below this statement indicating their knowledge and agreement that all of - or a portion of - their property is being considered for potential development Property owners agents will allow County Staff access to the property while conducting the review of this proposed development Owner Agent Signature Date _______________________________________________ __ ________________________ _____ __________________________________________ __ ________________________ _____ __________________________________________ ____ ______________________ Staff Use Only Fee ____________________________ Submittal Date __________________________ Email septicwellapplication @ johnstonncgov Subdivision Application Please copy for your recordsPage