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DocuSign Envelope ID:81E05E8E-EED7-43D3-8B8A-08110E72140A <br /> 1 <br /> F. <br /> Orange County Environmental Health <br /> PO Box 8181, 131 W Margaret Ln, Hillsborough, NC 27278 <br /> T e or rant le ibl . <br /> APPLICATION FOR PERMITS <br /> APPLICANT* Orange County Solid Waste PROPERTY OWNER* Orange County <br /> ADDRESS* 1207 Eubanks Road ADDRESS* PO Box 8181 <br /> Chapel Hill, NC 27516 Hillsborough, NC 27278 <br /> EMAIL* bwoody@orangecountync.goy EMAIL* <br /> DAYTIME PHONE NUMBER* 919-968-2788 DAYTIME PHONE* <br /> SITE ADDRESS: 3605 Walnut Grove Church Road, Hillsborough, NC <br /> DIRECTIONS/LOCATION* Located at the northwestern corner of the property. Lines are flagged. <br /> PIN* 9867419070 LOT SIZE 18,13 ac SUBDIVISION/LOT# <br /> *REQUIRED <br /> D NEW SEPTIC ❑NEW WELL ❑PERMIT REVISION:PERMIT# <br /> ❑EXPANSION OF SEPTIC SYSTEM(LE,ADDING BEDROOM) ❑WELL ABANDONMENT ❑SEPTIC SYSTEM ABANDONMENT <br /> ❑SEPTIC SYSTEM REPAIR ❑WELL REPAIR ❑SUBDIVISION/RECOMBINATION OF PROPERTY <br /> ❑EXISTING SEPTIC AUTHORIZATION OR CHANGE OF USE ❑WELL OR SEPTIC PERMIT RENEWAL:PERMIT# <br /> PROJECT DESCRIPTION(BE SPECIFIC)*REQUIRED: <br /> Installation of 2"forcemain and drainage field to manage wastewater produced by facility employees. 1f1 g <br /> []SINGLE FAMILY DWELLING *Number of Bedrooms: Number of occupants: <br /> ❑MULTI FAMILY:APARTMENT/GUEST HOUSE*Number of Bedrooms: Number of occupants: <br /> *REQUIRED <br /> ®BUSINESS/OTHER DOCUMENTATION OF TYPE,USAGE,NUMBER OF USERS/STAFF WILL BE REQUIRED. <br /> *WATER SUPPLY PLEASE CHECK IF APPLICABLE *REQUESTED SYSTEM MATERIAL <br /> ❑PUBLIC ❑BASEMENT WITH PLUMBING ®NO PREFERENCE <br /> ®PRIVATE WELL ❑WASTEWATER OTHER THAN SEWAGE GENERATED ❑CONVENTIONAL ONLY <br /> ❑COMMUNITY WELL ❑PROPERTY CONTAINS DESIGNATED WETLANDS ❑ACCEPTED MATERIALS <br /> ❑OTHER ❑SITE IS SUBJECT TO APPROVAL BY OTHER AGENCY ❑OTHER <br /> ❑GARBAGE DISPOSAL <br /> *REQUIRED ❑WATER SOFTENER *REQUIRED FOR IP/CA <br /> INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED.THE FOLLOWING IS REQUIRED. <br /> ❑SITE ASSESSMENT; A site assessment must be obtained from the Planning Department with jurisdiction over <br /> the property <br /> ❑SITE PLAN DRAWN TO SCALE: <br /> a. Existing and proposed property lines, easements, rights-of-way, and buffers with measurements; <br /> b. Location of all proposed structures, driveways, additions, other future Improvements with <br /> measurement of the structures and measures to two property lines (minimum); <br /> c. Known sources of contamination (septic drain fields, animal lots, fuel tanks, old wells); <br /> ❑FLOOR PLAN (not required for Well Permits or Residential Improvement Permits, other conditions apply for <br /> commercial projects) <br /> Please read before signing. Acknowledgment; This application has been signed by the current OWNER of the <br /> property or the OWNER'S LEGAL REPRESENTATIVE(documentation required) who has entered into a contract <br /> or lease with the owner and who may legally represent the property owner in the transactions regarding the <br /> property. Contact this office regarding digital signatures. 1, the undersigned, am the property OWNER or the <br /> LEGAL REPRESENTATIVE. By signing this application, I grant the Orange County Health Department, <br /> Environmental Health Division, right of entry to the property to perform the service(s)requested. <br /> r <br /> ti <br /> Q I <br /> OWNER/RE ; Ol _�� DATE: <br /> 1 <br />