Orange County NC Website
Browse       Search
r - <br /> APPLICANTS NAME TMBL Ssr. <br /> Orange County Health Department <br /> Environmental Health Division <br /> APPLICATION FOR PERMITS <br /> INFORMATIONGENERAL <br /> APPLICANT: PROPERTY OWNER.A <br /> ADD S ADDRESS <br /> kAWC N <br /> Email address' • 0 <br /> PRONE NUMBER •PINE NUMBER <br /> LOTSIZF SUBDIVISION l LOT# DATE LOT RECORDED <br /> PARCEL ADDRESS: DIRECTIONS!LOCATION: <br /> OC <br /> I,;this application for. RfNFW ❑REPAIR ❑EXPANSION ❑RENEWAL ❑SUBDIVISIONlRECOMB <br /> For a: SINGLE FAMILY DWELLING Siu Number of Bedrooms_!Z_ Number of occupants,�� <br /> APARTMENT .FFI IEN Y OF T H USE <br /> FIBUSINFSS/OTHER <br /> Please describe the business,number of employees,square footage,etc. Use auachments if necessary. <br /> TYPE OF WATER SUPPLY PL.ASE CHECK IF APPLICABLE- RFOLJFSTED&YSTEM TYPE: <br /> ❑PUBLIC EZ BASEMENT WITH PLUMBING jffCONVENTIONAL <br /> � RIVATE WELL [3,WASTEWATER OTHER THAN SEWAGE GENERATED ❑OTIIER(SPECIFY) <br /> J COMMUNfI'Y WELL ,~Sim bQ PROPERTY CONTAINS DESIGNATED WETLANDS <br /> ❑OTHER _CpAM J❑SITE IS SUBJECT TO APPROVAL BY OTHER AGENCY <br /> ❑FACILITY WILL HAVE A GARBAGE DISPOSAL OR WATER SOFTENER <br /> Check All Sections That Apply <br /> F-1 WELL PERMIT SECTION # <br /> ❑WELL PERMIT-NEW $230 <br /> ❑WELL PERMIT-RENEWAL/ALTERATIONS/REVISIT $100 <br /> CHAT THE FOLLOWING ARE REQUIRED BEFORE PROCESSING THIS APPLICATION FOR A WELL PERMIT: <br /> O A SITE PLAN OR PLAT MUST BE PROVIDED SHOWING:THE 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 /> ❑ EXISTING WELL I WASTEWATER AUTHORIZATION • # <br /> ❑EXISTING SEPTIC SYSTEM INSPECTION WITH NO INCREASE IN WASTEFLOW $100 <br /> DESCRIPTION OF PROPOSED CHANGES!REASON FOR INSPECTION: <br /> ORIGINAL OWNER SYSTEM IS: ❑IN USE or ❑VACANT since (date) <br /> CHECKLIST THE FOLLOWING ARE REQUIRED BEFORE PROCESSING THIS APPLICATION FOR AN INSPECTION: <br /> U A SITE PLAN OR PLAT MUST BE PROVIDED SHOWING:THE LOCATION OF ANY STRUCTURES,PROPOSED <br /> ADDITIONS,EXCAVATIONS OR OTHER IMPROVEMENTS;AND PROPERTY LINES. <br /> U FOR ADDITIONS,A COPY OF THE FLOOR PLAN MUST BE SUBMITTED FOR REVIEW. <br /> U EXISTING PROPERTY LINES,CORNERS,AND LOCATION OF PROPOSED STRUCTURES MUST BE CLEARLY MARKED <br /> ON THE SITE. <br /> Eli MOBILE HOME PARK RECONNECTION SECTION <br /> ❑MOBILE HOME SPACE RECONNECTION INSPECTiON-PER SPACE $50 <br /> CHECMAT THE FOLLOWING ARE REQUIRED BEFORE PROCESSING THIS APPLICATION FOR AN INSPECTION: <br /> U A SITE PLAN OR PLAT MUST BE PROVIDED SHOWING:THE DIMENSIONS AND LOCATION OF THE PROPOSED <br /> MOBILE HOME. <br /> U THE CORNERS OF THE PROPOSED HOME MUST BE CLEARLY STAKED ON THE SITE. <br /> U A COPY OF THE FLOOR PLAN MUST BE SUBMITTED FOR REVEEW. <br /> APPLICATION#: L j�a5'QC�� — PIN#r <br /> DATE RECEIVED: 1 OCP€I CONFIRMED: <br /> REVIEWED By, - -ASSIGNEDTO: JI?►+ <br /> 074NOTES:: 187 <br />