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Orange County Health Department-Environmental Health Division pTN: <br /> APPLICATION FOR PERMITS <br /> GENERAL INFORMATION <br /> APPLICANT. (Polka /PROPERTY OWNERJ% AA; <br /> ��1ij <br /> ADDRESS ADDRESS ssssss� k�J <br /> E r .1L. NC 2_72g3 �r,�rl�r, NC 2�15z9 Xe�.l�%�t�f�as•� <br /> EMAIL EMAIL ' <br /> PHONE NUMBfR I . PHONE NUMBER S ^_�5 je <br /> LOT SIZE SLJBDNISION/LOTH C4L ut Rt DATE LOT RECORDED <br /> CATION ADDRESS: `F DIItECTION3/LOCATION: <br /> PROJECT -- <br /> ®NEW BUILDING ❑EXPANSION TO EXISTING FACILITY ❑SFPTIC SYSTEM REPAIR <br /> ❑WELL OR SEPTIC PERMIT RENEWAL ❑PERMIT REvisiON ❑WELT..REPAIR <br /> ❑ABANDONMENT OF WELL OR SEPTIC SYSTEM ❑SUBDIVISION/RFCOMBINATION OF PROPERTY <br /> PRfiaECT DESCRwriopi:-Ilith".1 C1 L�aLrf� _ saAir 4t,11[ ,r .,a 'fit S:A_ <br /> L' <br /> Size Number of Bedrooms. Z Numbcr of occupants- <br /> BUSINESSlOTHER <br /> Please describe the business:number of employees, days/hours of operation,etc. Use attachments if necessary. <br /> W <br /> PU$I IC BASEMENT WITH PLUMBING No Preference <br /> PRIVATE WELL ❑WASTEWATER OTHER THAN SEWAGE GENERATED ❑Accepted System gravity <br /> COMMUNITY WELL ❑PROPERTY CONTAINS DESIGNATED WETLANDS ❑Conventinnal Septic System <br /> ❑OTHER ❑SITE IS SUBJECT TO APPROVAL BY OTHER AGENCY ❑Innavative = <br /> ❑WILT.HAVE A GARBAGE DISPOSAL Pump to: <br /> ❑WILL HAVE A WATER SOFTENER r Othcr <br /> P RTANT;ALL APPLICATIQNS MUST CONTAING INFORMATION I R TO BE PROCESSED: <br /> —A SITE PLAN OR PLAT SHOWING: 'EXISTING AND ANY PROPOSED PROPERTY LINES,EASEMENTS.RIGHTS-OEWAY,AND SUFFCRS WITH Dl <br /> •LOCATION OF ALL PROPOSED STRUCTURES,DRIVEWAYS,ADDITIONS,OR <br /> OTHER IMPROVEMENTS LABELED WITH SETBACKS INDICATED. <br /> --A PLANNINCUZONING SITE ASSESSMENT: -SITE PLAN ASSESSMENT FROM LOCAL PLANNING DEPARTMENT WITH <br /> JURISDICTION FOR THIS PROPERTY 13 REQUIRED. <br /> —A FLOOR PLAN OF THE STRUCTURE: •(NOT REQUIRED FOR WELL OR IMPROVEMENT PERMIT APPLICATIONS) <br /> FOR ADDITIONS, A FLOOR PLAN SHOWING BOTH CURRENT AND PROPOSED <br /> STRUCTURES IS REQUIRED. <br /> --THE FOLLOWING MUST BE STAKED ON SITE1 •LOCATIONS OF PROPOSED STRUCTURES: FAISTINO AND PROPOSED <br /> PROPERTY LINESIOORNERSfEASEMENTB:STREAM BUFFERS <br /> SIGNATURE SECTION <br /> TOTAL AMOUNT DUE: S t R@C'EIPT ! 6 <br /> Make chocks paytltbl•to:Orsapr County Health Department <br /> THIS APPLICATION MUST BE SIGNED BY THE CURRENT OWNER OF THE PROPERTY OR THE OWNER'S LEGAL <br /> REPRESENTATIVE (e.t., SPOUSE, POWER OF ATTORNEY, EXECUTOR, OR OTHER LICENSED PROFESSIONAL (ATTORNEY, <br /> REALTOR. BUILDER,tic.)WHO HAS ENTERED INTO A CONTRACT OR LEASE WITH THE OWNER AND WHO CAN LEGALLY <br /> REPRESENT THE PROPERTY OWNER IN TRANSACTIONS REGARDING THE PROPERTY) <br /> 1 AM THE PROPERTY OWNER OR THE PROPERTY OWNER'S LEGAL REPRESENTATIVE,I HAVE READ THIS APPLICATION AND <br /> AUTHORIZE THE OCHD TO ENTER THE PROPERTY AND PERFORM THE SERVICE(S)REQUESTED. <br /> I LWDERSTAND TH I AM POIVSMLE FOR MAKING THE SITE ACCESSIBLE FOR THE EVALUATIOWPERMIMNG <br /> PROCESS. <br /> OWNER DATE a f <br /> . ✓� ! �—�� <br /> ONLY R GI GNATURES CAN BE ACCEPTED <br /> S(ENVIRONMENTAL HEALTH SERVICEMNSITE FROGRAMWOR-�ISTaemit Appltcation_July 1,2017 <br /> 272 <br />