Orange County NC Website
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APPLICANT'S NAME TMBL I I - ( / 0 C� <br /> 184 <br /> Orange County Health-Department <br /> Environmental Health Division <br /> ► it g <br /> 4 'a <br /> 7t tc� <br /> r <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 permit/authorrzation is issued. <br /> Orange County Health Department,Environmental Health Division <br /> P.O.Box 8181,306-C Revere Road <br /> Hillsborough,ITC 27278 <br /> PHONE:919-245-2360 FAX:919-644-3006 <br /> www.co.omnge.nc.us <br /> TV <br /> .. .::.A �:T... <br /> APPUCATIOH , - PIN <br /> r : ' 1 P ' <br /> DATE REGENED' p ' ___:. DCPD CONFIRMED <br /> REVIEWED BY C ASSIGNED TO V W <br /> NOTES: <br />