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EVALUATIONSITE - • • # <br /> ❑IMPROVEMENT PERMIT(Up to 600 GPD) NUMBER OF SITES X $310 PI,-R SITE <br /> INDIVIDUAL LOT ❑ SUBDIVISION ❑ RECOMBINATION❑ EXISTING SYSTEM❑ EXPANSION❑ <br /> ❑SITE REVISIT TO REISSUE OR MODIFY A VALID IMPROVEMENT PERMIT(Up to 600 GPD) $100 PER SITE; <br /> FACII SITF,EVALUATION COA'SISTS OF UP TO 2 ACRF_S. FI,OIVS OVF,R 600 GPD RF. U1RF,ADDITIONAL FF_FS. <br /> CHMnus_4 THE FOLLOWING ARE REQUIRED BEFORE PROCESSING THIS APPLICATION FOR AN IMPROVEMENT <br /> PERMIT: <br /> O A SITE PLAN OR PLAT SHOWING THE EXISTING AND PROPOSED PROPERTY LINES WITH DIMENSIONS AND THE <br /> LOCATION OF ALL PROPOSED STRUCTURES,ADDITIONS,OR IMPROVEMENTS WITH LABELED SETRACKS. <br /> O EXISTING AND ANY PROPOSED PROPERTY LINTS I CORNERS MUST BE CLEARLY MARKED ON SITE, <br /> O THE APPLICANT IS RESPONSIBLE FOR MAKING THE SITE ACCESSIBLE FOR THE EVALUATION. <br /> O FOR NON SINGLE-FAMILY DWELLING APPLICATIONS,ADDITIONAL INFORMATION TO DETERMINE WASTE FLOW <br /> AND CHARACTERISTICS WILL,BE REQUIRED. <br /> CONSTRUCTION AUTHORIZATION SECTI• <br /> WAUTHORIZATION TO CONSTRUCT FOR NEW CONSTRUCTION OR EXPANSION $160(Up to 600 GPD) <br /> ❑SITE REVISIT TO REISSUE OR MODIFY A VALID CONSTRUCTION AUTHORIZATION $ 100(Up to 600 GPD) <br /> cxgr,KLL.IRT THE FOLLOWING ARE REQUIRED BEFORE PROCESSING THIS APPLICATION FOR A CONSTRUCTION <br /> / AUTHORIZATION: <br /> 10 A FLOOR PLAN OF THE:STRUCTURE,MUST BE SUBMITTED. <br /> �4 A SITE PLAN OR PLAT CRUST BE PROVIDED SHOWING:THE LOCATION OF THE PROPOSED STRUCTURES, <br /> DRIVEWAYS,ADDITIONS,EXCAVATIONS OR OTHER IM IPROVEMEN s;PROPERTY LINES;DIMENSIONS,AND <br /> SETBACKS TO REFERENCE POINTS. <br /> 41, THE EXISTING AND ANY PROPOSED PROPERTY LINES I CORNERS MUST BE CLEARLY MARKED ON STTE. <br /> J THE LOCATION OF PROPOSED STRUCTURES AND IMPROVEMENTS MUST BE STAKED ON SITE. <br /> THE CONSTRUCTION AUTHORIZATION MUST BE ISSUED PRIOR TO ANY CONSTRUCTION. SUBSEQUENT CHANGES TO <br /> THE SITE PLAN,FLOOR PLAN,OR APPLICATION WILL REQUIRE A NEW APPLICATION AND ADDITIONAL FEES. FLOWS <br /> OVER 600 GPD REQUIRE ADDITIONAL FEES. <br /> SIGNATURE <br /> • r, <br /> ❑ TOTAL AMOUNT DUE: $JGD. cG RECEIPT# P—DS-b <br /> IF THE RESULTING FLOW IS>600 GPD,FOR NON-DOMESTIC WASTEWATER SYSTEMS, OR IF AD_DITIDNAL PERMITS ARE <br /> NLQRSSARY PLEASE CHECK WITH.EN V I RQNM ENTAL HEALTH TO DISCUSS THE AMOUNT 0 E'A DDITO NAL FEES. <br /> 'THIS APPLICATION MUST BE SIGNED BY THE CURRENT OWNER OF THE PROPERTY OR THE OWNER'S LEGAL <br /> REPRESENTATIVE(eq.SPOUSE,POWER OF ATTORNEY,EXECUTOR,OR PERSON WHO HAS ENTERED INTO A <br /> CONTRACT OR LEASE WITH THE PROPERTY OWNER) <br /> ONLY ORIGINAL SIGNATURES CAN BE ACCEPTED. <br /> I AM THE PROPERTY OWNER OR THE PROPERTY OWNER'S LEGAL REPRESENTATIVE <br /> I HAVE READ THIS APPLICATION AND AUTHORIZE THE OCHD TO ENTER THE PROPERTY AND PERFORM THE SERVICE(S) <br /> REQUESTED. <br /> OWNER: / "4 DATE: <br /> Please mail or bring in the first two pages of this completed form, with payment including the <br /> signature of the owner* a floor plan (where applicable)and a site plan as indicated. Please call <br /> our office if you have any questions about filling out this form or the amount of payment <br /> needed. Make checks payable to : Orange County Health Department <br /> Return first 2 pages to: <br /> Orange County Health Department <br /> Environmental Health Division <br /> 306-C Revere Rd. <br /> Hillsborough, NC 27278 <br /> 07/03 186 <br />