Orange County NC Website
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APPLICANT'S NAME I1([�C(/� �L �� TMBL -3• � . <br /> Orange County Health Department <br /> Environmental Health Division <br /> -er@,kA&,. 4 .cam <br /> Crc`4[? <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 form 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 property. Any <br /> permit may be suspended or revoked if the information is falsified, incorrect or if the <br /> site is altered after the permitlauthorization is issued <br /> Orange County Health Department,Environmental Health Division <br /> P.O.Box 8181,306-C Revere Road <br /> Hillsborough,NC 27278 <br /> PHONE: 919-245-2360 FAX:919-644-3006 <br /> www.co.orange.ne.us <br /> APPLICATION#: PIN#: <br /> DATE RECEIVED: OCPD CONFIRMED: <br /> REVIEWED BY: �' , ASSIGNED TO: <br /> NOTES: <br /> Ex -�)yj <br /> L <br /> 238 <br />