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.

     Environmental Health Fee Schedule - McDowell pdf button
     Environmental Health Fee Schedule - Polkpdf button
     Environmental Health Fee Schedule - Rutherford pdf button

     Refund Request Form (RPM 4001.019)pdf button


Documents Pertaining to Septic Systems
     Septic System Repair and Existing Septic System Instruction Sheet (RPM 4001.031)pdf button
     Septic System Repair and Existing Septic System Application (RPM 4001.034)pdf button
     Application for Well or Septic System Services (RPM 4001.029)pdf button
     Sample Site Plan (RPM 4001.004)pdf button

     Misc. Septic System Documents
          Pump Tank Diagram (RPM 4001.035)pdf button
          Pump Installer Registration (RPM 4001.036)pdf button
          General Construction & Location of Pits for Health Dept. Evaluation (RPM 4001.037)pdf button
          Health Department Site Evaluation Sign - Orange (RPM 4001.005)pdf button
          Legal Agent Verification Form (RPM 4001.016)pdf button
          Septic & Well Application Site Plan Requirements (RPM 4001.038)pdf button
          Septic Installer List Page (from State of North Carolina)

Documents Pertaining to Water Wells
     Water Sample Request Application (RPM 4001.020)pdf button
     Home Owner Well Repair Application (RPM 4001.039)pdf button
     Water Quality Guide (RPM 4001.040)pdf button
     Well Disinfection Brochure (Link to State of North Carolina)
     RPM Well Procedures (RPM 4001.017)pdf button
     Well Driller Registration (RPM 4001.041)pdf button
     Well Owner Statement (RPM 4001.042)pdf button
     Well Repair & Pump Repair Notification (RPM 4001.018)pdf button
     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 Record (Form GW-1)
          Well Abandonment Record (Form GW-30)


Documents Pertaining to Child Care Facilities

     Child Care Facility Application (RPM 4001.043)pdf button


Documents Pertaining to Tattooing
     Application for Tattooing Permit (State Form DENR 4015)pdf button

Documents Pertaining to Swimming Pools
     Public Swimming Pool Application (RPM 4001.054)pdf button
     Application to Construct, Install Remodel or Modify a Public Swimming Pool (RPM 4001.058)

Documents Pertaining to Food Service Establishments
 Food Service Establishment Application (RPM 4001.057)pdf button
     Application For Pushcart Or Mobile Food Unit (RPM 4001.055)pdf button

Documents Pertaining to Temporary Food Establishments
     Temporary Food Establishment Packet (RPM 4001.002)pdf button
     Temporary Food Establishment Coordinator Sheet (RPM 4001.003)pdf button
     Rules Governing the Sanitation of Food Service Establishments (NC Administrative Code) - New Link Coming Soon!

 Documents Pertaining to Resident Camps

     Advance Notification For Seasonal Operation (DENR 3602) 

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)pdf button
     Health Department Limited Power of Attorney (RPM 4001.046)pdf button
     Environmental Health Customer Satisfaction Survey - English (RPM 4001.022)pdf button
     Environmental Health Customer Satisfaction Survey - Spanish (RPM 4001.032)pdf button
     Legal Agent Verification Form (RPM 4001.016)pdf button

Link to RPM Health District Facebook Page
Link to RPM Health District's Twitter Page
Link to RPM Health District's YouTube Page