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5 <br />No~th Carolina VI-aterlWastewater Common Appiication Form <br />~ Far use by ARC, CWMTF, DENR DOC, and Rura1 Center appticants. <br />GENERAE INFORMATION <br />Legal Name of Appticant / Unit Orange County County: Orange <br />Name of Chief Etectec! Offi«al: Bemadette Pelissier Trtle: Chair <br />Name of Autharized Representatinre (f different from above}: Prank Ctifton, County Manager I <br />Mailing Address: P.O. Box 8181 Street Address: 200 East Margaret Lane <br />City: Hillsboraugh Stafe: KC Zip: 27278 <br />Primary i'elephone{s}: 999-245-23oa Fa~c 919-644-3004 <br />Etnail: fctiftonCa7co.oranae.nc.us <br />7y~e of Appficaryt {check those that applyj: <br />^ Municipatity ^ Water / Sewer District <br />~ Courity ^ Metro Water / Sewer District <br />^ Non Profit Water Corporation ^ Wafer / Sewer AuthoriEy <br />^ Other (be speafic}: _ <br />Federal Tax ID #: <br />^ Joint Agency Pursuant to G.S. 16QA-20 <br />^ JointAgency Pucsuantto G.S. 63-56 <br />^ Sanitary District <br />ApgFica~ion Prepared by: <br />Name_ R. Kevin Lindley Title: Staff Engineer <br />Pr"unary Telephone: 519-245-2583 Fax 319-644-3002 <br />Emaif: klindfeVCc~co.oranqe.nc.us <br />Name of Engineering Firm: MaGili Associafes , <br />Mame of Engineer: Doug Chapman <br />MaiGng Address (if other than above): _ i23619'" Street, Lane NW <br />Cifyr: Hickory State: NC Zip: <br />Primary Teiephone: 828-32&2024 Fa~c 82&328-3870 <br />Emati: doug.chapmanQma~~Rengmeers.com Federal Tax ID #: <br /> <br />PROJECT TYPE Check ali that appty: <br />. DRINKfNG WA'fER WASTEWA7ER <br />brfnking Water Source ^ Wastewater Treatment ^ <br />Drinking WaferTreatment ^ Wastewater ColEecfion ~ <br />Drinking Water TransmissEon/Uistributfon ^ Water Recfamation or Land Application facitities ^ <br />Drinking Water Sforage ^ Sewer System Rehab ^ <br />Other: exgfain in projecE descriptlon ~ Ofher. explain in praject descripfion ~ <br />(Including green projects} (Including green projects) <br />Projecfed Construction START Date: Qdober 2012 County(s) Served: Orange <br /># of NEW customers (connecUons} <br />TO 8E SERVED by project <br />Water Wastewafer <br />Residential 2 ~ <br />Business ~. . . _- _- -~ Na <br />Total(s) 2 <br />28&03 <br /># of customers (connectlons) CURRENTLY served <br />• Water Wastewafer <br />Residenfiai 220 <br />Business 5 <br />TataE(s) 225 <br />Page 2 of 5 <br />Version 09/70 <br />