Orange County NC Website
Browse       Search
APPLICANT'S NAME TMBL • 6:) • . <br /> Orange County Health Department <br /> ((DU Environmental Health Division <br /> APPLICATION FOR PERMITS <br /> INFORMATIONGENERAL <br /> APPLICANT`:' /r �pp l+�bP�RROPERTY OWNER: A _a [��r/7�ug7s/Cs��/1�• <br /> AD EiSS yisx AK DRESS <br /> AhM <br /> C <br /> fiusail address; � II .Qll'� �/e <br /> PHONE NUMBERjft PHONE NUMBER �G��T7-yy33 x.Zr <br /> LOT Sl7_I SUBDIVISION/LOT# DATE LOT RECORDED <br /> PARCEL ADDRESS: Cgte C6.t�E.jSeDIRECTIONS/LOCATION: <br /> Is this application tor: NEW REPAIR ❑EXPANSION ❑RENEWAL ❑SUBDIVISION/KECOMB <br /> Fora: bQSINGLE FAM11,Y DR'ELI,ING Size l�'7.��Number of Bedrooms Number of occupants L <br /> ❑APARTMENTIFFFICIENCYIGUEST H USE <br /> ❑BUSINESSlOTHER <br /> Please describe the business,number of employees,square footage.etc. Use attachments if necessary. <br /> TYPE OF WATER SUPPLY Pl,'ASE CHECK IF APPLICABLE: RE UESTF. YSTEM[TYPE: <br /> ❑PUBLIC 6jrBASEMFNT WITH PLUMBING RrCONVENTIOi7AL <br /> PRIVATE WELL y ❑WASTEWATER OTHER THAN SEWAGE GENERATED [--]OTHER(SPECIFY) <br /> COMMUNITY WELL r RlllStL�G Pf ROPERTY CONTAINS DESIGNATED WETLANDS <br /> ❑OTHER Nam_ 1pWAttJ} ❑SITE IS SUBJECT TO APPROVAL BY OTHER AGENCY <br /> 1! ❑FACILITY WILL HAVE A GARBAGE DISPOSAL OR WATER SOFTENER <br /> Check All Sections That Apply <br /> ❑ WELL PERMIT SECTION # <br /> ❑WELL PERMIT-NEW $230 <br /> ❑WELL PERMIT-RENEWAL!ALTERATIONS I REVISIT $ 100 <br /> CMEChLOSg THE FOLLOWING ARE REQUIRED BEFORE PROCESSING THIS APPLICATION FOR A WELL PERMIT: <br /> O A SITE PLAN OR PLAT MUST BE PROVIDED SHOWING:THI?LOCATION ANY STRUCTURES,PROPOSED ADDITIONS, <br /> EXCAVATIONS OR OTHER IMPROVEMENTS:AND PROPERTY LINES. <br /> O THE EXISTING AND PROPOSED PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. <br /> A . • • SECTION # <br /> El F-1 <br /> XfSTING SEPTIC SYSTEM INSPECTION WITH NO INCREASE IN WASTEFLO11' S 100 <br /> DESCRIPTION OI'PROPOSED CHANGES/REASON FOR INSPECTION: <br /> ORIGINAL OWNER SYSTEM IS: ❑IN USE or ❑VACANT since (date) <br /> CHECIAWST THE FOLLOWING ARE REQUIRED BEFORE PROCESSING THIS APPLICATION FOR AN INSPECTION: <br /> O A Sl'I'F,PLAN OR PLAT MUST BE PROVIDED SHOWING:THE LOCATION OF ANY STRUCTURES,PROPOSED <br /> ADDITIONS,EXCAVATIONS OR OTHER IMPROVEMENTS;AND PROPERTY LINES. <br /> O FOR ADDITIONS,A COPY OF THE FLOOR PLAN MUST BE SUBMITTED FOR REVIEW. <br /> O EXISTING PROPERTY LINES,CORNERS,AND LOCATION OF PROPOSED STRUCTURES MUST BE CLEARLY MARKED <br /> ON THE SITE. <br /> MOBILE[ i <br /> •ME PARK RECONNECTION SECTION # <br /> ❑MOBILE:HOME SPACE RECONNECTION INSPECTION-PER SPACE: $50 <br /> s( <br /> CHECKUBT THE FOLLOWING ARE REQUIRED BEFORE PROCESSING THIS APPLICATION FOR AN INSPECTION: `mod <br /> O A SITE PLAT OR PLAT MUST BE PROVIDED SHOWING:THE DIMENSIONS AND LOCATION OF THE PROPOSED <br /> MOBILE HOME. <br /> O THE CORNERS OF THE PROPOSED HOME MUST BE CLEARLY STAKED ON THE SITE. <br /> O A COPY OF THE FLOOR PLAN MUST BE SUBMITTED FOR REVIEW. <br /> APPLICATION#: Ao - 004 PIN#: y t <br /> DATE RECEIVED: ,) OCPD CONFIRMED: 4 <br /> REVIEWED BY: ASSIGNED TO: VVX <br /> 07d NOTES: 185 <br />