Orange County NC Website
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APPLICANT'S NAME TMBL S--ST" <br /> T <br /> Orange County Health Department <br /> Environmental Health Division <br /> �vt! Val <br /> APPLICATION FOR PERMITS <br /> Improvement Permits <br /> Construction Authorizations <br /> Existing Well/Septic System Inspections <br /> Well Permits <br /> This application is used to apply for any or all of the above permits or authorizations. <br /> The form must be filled out completely and accompanied with payment before services <br /> can be initiated <br /> Completion of this foray does not imply or guarantee any permit will be issued or an <br /> authorization granted. Please be sure all the information is correct as the information <br /> you provide will guide the staff in the evaluation and permitting of your properly. Any <br /> permit may be suspended or revoked if the information is falsified, incorrect or if the <br /> site is altered after the permit/authorrzation is issued. <br /> Orange County Health Department,Environmental Health Division <br /> P_Q. Boa 8181,346-C Revere Road <br /> Hillsborough,NC 27278 <br /> PHONE: 919-2,45-2360 FAX: 919444,3006 <br /> www.co.orange.nc.us <br /> APPUCATION#: PIN#: <br /> DATE RECEIVED: _ OCPD CONFIRI IED: <br /> .<5,"�L� <br /> REVIEWED BY: ^� ASSIGNED TO: <br /> NOTES: <br /> 206 <br />