ORANGE COUNTY HEALTH DEPARTMENT

APPLICATION FOR ON-SITE SEWAGE FACILITY

AMOUNT $________ RECEIPT #__________ DATE____________ PERMIT #__________

FOR USE BY ORANGE COUNTY HEALTH DEPARTMENT ONLY

 

PROPERTY OWNER’S NAME: ________________________________________________

(First) (Middle) (Last)

MAILING ADDRESS: ________________________________________________________

(# & Street Name (or) P. O. Box # (or) Route # & Box #) (City) (Zip)

TELEPHONE NUMBER: ______________________________________________________

(Home) and (Work) and/or (Other)

SITE ADDRESS: _____________________________________________________________

(# & Street Name (or) Route #, Box # & Name of Road (or) 911 Address) (City) (Zip)

(Address Required)

 

LEGAL DESCRIPTION

(As Recorded at Appraisal District)

Lot #: _____ Block #: _____ Subdivision Name: _____________________ Lot Size: _________

OTHER THAN SUBDIVISION:

Abstract #: ______ Survey Name: _________________ Tract #: ________ Section #: _______ Acreage: _________

DAILY WATER FLOW

MAXIMUM DAILY WATER CONSUMPTION (Gallons Per Day):______. Actual Estimated

(Required)

SOURCE OF WATER: Private Well Public Water Supply - Name: _____________________

SINGLE FAMILY RESIDENCE: Number of Bedrooms: _____ Living Area (Square Feet): _________

(Required)

NAME OF BUSINESS_________________________________________

COMMERICAL/INSTITUTIONAL (Including Multi-Family Residences) TYPE_______________

NUMBER OF EMPLOYEES/OCCUPANTS/UNITS: ___ DAYS OCUPIED PER WEEK: _______

DESIGNER:__________________________ REGISTRATION NUMBER: ___________________

ADDRESS: __________________________ PHONE NUMBER: __________________________

INSTALLER: ________________________ REGISTRATION NUMBER: ___________________

ADDRESS: ___________________________ PHONE NUMBER: __________________________

I hereby certify under penalty of law that this application and any attachments contain no willful or negligent misrepresentation or falsification and that all information is true, accurate, and complete. I understand that any misrepresentation or falsification may result in rejection of my application or in revocation of any permit issued as a result of this application. Authorization is hereby given to the Orange County Health Department to enter upon the above-described property for the purpose of lot evaluation and inspection. A Permit to Operate the facility will be granted following successful inspection of the installed system, which indicates that the system was installed in compliance with TNRCC’s "Construction Standards For On-Site Sewage Facilities".

_______________________________ ____________________________________

(Signature of Owner) (Date)