Environmental Health Forms
Below is a complete listing of available Rutherford Polk McDowell Health District Environmental Forms. They are grouped as close as possible to the program they relate to.
Fees
McDowell County Environmental Fee Schedule (RPM 4001.001_M)
Polk County Environmental Fee Schedule (RPM 4001.001_P)
Rutherford County Environmental Fee Schedule (RPM 4001.001_R)
Refund Request Form (RPM 4001.019)
Documents Pertaining to Septic Systems
Septic System Repair and Existing Septic System Instruction Sheet (RPM 4001.031)
Septic System Repair and Existing Septic System Questionnaire (RPM 4001.034)
Application for Services (RPM 4001.029)
Sample Site Plan (RPM 4001.004)
Misc. Septic System Documents
Pump Tank Diagram (RPM 4001.035)
Pump Installer Registration (RPM 4001.036)
General Construction & Location of Pits for Health Dept. Evaluation (RPM 4001.037)
Health Department Site Evaluation Sign - Orange (RPM 4001.005)
Legal Agent Verification Form (RPM 4001.016)
Septic & Well Application Site Plan Requirements (RPM 4001.038)
Septic Installer List Page (from State of North Carolina)
Documents Pertaining to Water Wells
Water Sample Request Instructions (RPM 4001.021)
Water Sample Request Application (RPM 4001.020)
Home Owner Well Repair Application (RPM 4001.039)
Water Quality Guide (RPM 4001.040)
Well Disinfection Brochure (Link to State of North Carolina)
RPM Well Procedures (RPM 4001.017)
Well Driller Registration (RPM 4001.041)
Well Owner Statement (RPM 4001.042)
Well Repair & Pump Repair Notification (RPM 4001.018)
Well Driller Listing (Link to State of North Carolina)
North Carolina Law Pertaining to Water Wells
Well Construction, Monitoring & Abandonment Link from NC Divisions of Water Quality
Well Construction, Residential (Form GW-1a)
Well Construction, Non-Residential (Form GW-1b)
Well Abandonment Record (Form GW-30)
Documents Pertaining to Child Care Facilities
Child Care Facility Application (RPM 4001.043)
Documents Pertaining to Tattooing
Application for Tattooing Permit (State Form DENR 4015)
Documents Pertaining to Swimming Pools
Public Swimming Pool Application (RPM 4001.054)
Swimming Pool Data Sheet (RPM 4001.044)
Documents Pertaining to Temporary Food Establishments
Temporary Food Establishment Packet (RPM 4001.002)
Temporary Food Establishment Coordinator Sheet (RPM 4001.003)
Rules Governing the Sanitation of Food Service Establishments (NC Administrative Code)
State Water Lab Sample Lookup
Inorganic Sample Lookup
Inorganic Sample Results Explanation
Bacteriological Sample Lookup
EPA Primary Drinking Water Standards
EPA Secondary Drinking Water Standards
General Environmental Health Forms
Environmental Health Records Request (RPM 4001.045)
Health Department Limited Power of Attorney (RPM 4001.046)
Environmental Health Customer Satisfaction Survey - English (RPM 4001.022)
Environmental Health Customer Satisfaction Survey - Spanish (RPM 4001.032)
Legal Agent Verification Form (RPM 4001.016)
