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n u"'AH T 1iMENT-ENVIRONMENTAL HEALTH DIVISION <br /> -- APPLICATION FOR SOIUSITE EVALUATION <br /> APPLICANT ' ( am PIJE� OWNER <br /> ADDRESS P O. &OX I <br /> I2-0-b7 ADDRESS 1000 �,UA.oe V <br /> ATP I N L 27701 N Z C, <br /> PHONE (DAYTIME) �5ta sl `i�t 1- °1000 PHONE(DAYTIME) at9 <br /> 00 thatb PU (0S `t 23 <br /> TAX MAP REFERENCE: _r� 159b PCB �"< TOWNSHIP;TAX MAP-4:4 BL CK P' LOT 2'6 A <br /> DIRECTIONS TO PROPERTY(USE SPECIFIC ROAD NAMES OR NUMBERS WITH EXACT DISTAN ES): <br /> m-V-- or DAv'-oo•Lj-:e- 0 1 3 IitL 5 r.p g� <br /> PLEASE FILL 0 ALLz, Qht ASCO�fFLETELYrtS �OS519 FRI UftE7...0 DQ SO <br /> 4fAY B CEIIUVSLD_i=R1rfI,AN-'INC R! E APijLlCAT JOlsi R11?f1 r✓F1f1f ET>�7EpAYsTNL; <br /> Cviu. f170/r t' f,�Y S irw"i= xf� ?3 SJtFry�srx,E�f$"s > �� _ �i ix u it <br /> WHAT IS THE EXACT ACREAGE OF THE EXISTING PROPERTY? 2 •UCo(p <br /> WHAT IS THE ACREAGE OF THE SITE TO BE CHECKED? 0• <br /> ARE THE PROPERTY CORNERS AND LINES CLEARLY MARKED? 5 <br /> WHEN WAS THE PROPERTY LAST SURVEYED? 22 <br /> PROPOSED USE FOR PROPERTY: SINGLE FAMILY DWELLING BUSINESS OTHER <br /> (UST ALL ROOMS,NUMBER OF EMPLOYEES,ETC.) <br /> IS THERE A WASTEWATER SYSTEM CURRENTLY ON THE PROPERTY? IS THE S STEM IN USE? S <br /> IS THERE A WELL OR SPRING ON THE PROPERTY? WILL ONE BE NEEDED? 00 <br /> . <br /> DIAGRAM THE PROPERTY WITH DIMENSIONS IN THE SPACE BELOW IF THERE IS NOT AN ACC MPANYING PLAT WITH <br /> THIS APPLICATION. PLEASE INDICATE THE LOCATION OF ANY PROPOSED STRUCTURES,ET . <br /> Svc.- s,.�,.�lo.�--• <br /> l <br /> PLEASE SIGN BELOW THAT YOU UNDERSTAND THE PROVISIONS OF THE APPLICATION AND A SO THAT THE <br /> REPRESENTATIVE OF THE ORANGE COUNTY HEALTH DEPARTMENT HAS PERMISSION FROM E PROPERTY OWNER <br /> TO ENTER THE PROPERTY TO CONDUCT THE SOILISITE EVALUATION. UNSIGNED APPLICATIO S WILL NOT BE <br /> PROCESSED. (' <br /> DATE <br /> WN AUTHOR D AGENT <br /> PAYMENT MUST BE INCLUDED WITH THIS APPLICATION TO COMPLETE SERVICES.-SOIL EVALLIATION-i424 PER S (UP TO 2 ACRES) <br /> RETURN TO: ORANGE COUNTY HEALTH DEPARTMENT,ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 8181,308-C REVERE RO.,HILLSBOROUGH,NC,27278, <br /> SITE CLASSIFICATION S ACTION TAKEN r 1P s <br /> IMPROVEMENT <br /> REFER TO THE ATTACHED pSURVEYEO PLAT OR RITE PLAN FOR THE LOCATION OF THE ESIGNATEO AREA. <br /> THIS PERMIT SHALL BE VALID 0 WITHOUT EXPIRATION XFOR A PERIOD OF 5 YEARS FROM THE TE OF ISSUANCE <br /> WASTEFLOW—L-90 _GPD TYPE SYSTEM CONVl- LTAR -2 MAX TRENCH PTH 8 <br /> TYPE SYSTEM Tr C- THERE MAY BE OTHER TYPES OF SYSTEMS WHICH ARE APPLICABLE FOR IS SITE. <br /> THE APPLICANT FOR AN AUTHORIZATION TO CONSTRUCT MUST SPECIFY THE SYSTEM TYPE(S) O BE CONSIDERED. <br /> OTHER PERMIT CONDITIONS: 13AAAJC Q4 t pnsl lwot6 a.+u. fl <br /> Z M I s , l a 46. rTe It <br /> A CONSTRUCTION AUTHORIZATION MUST BE ISSUED PRIOR TO THE ISSUANCE OF THE BUILDING PER T AND BEFORE ANY <br /> CONSTRUCTION,OR SYSTEM INSTALLATION CAN COMMENCE <br /> THIS PERMIT IS SUBJECT TO REVOCATION IF THE SITE PLAN,PLAT,OR INTE USE CHA ES OR SITE IS ALTERED. <br /> S 2L 199- <br /> OAT F VI ME AL HEALTH SPEC1 UST <br />