Application For Operation Permit Renewal Form - Montgomery County Health Department printable pdf download

Parcel ID#: ____________________________

Department Use Only

(available at Tax Office)

Application #: ____________________

Application Date: ____________________

Montgomery County Health Department

Environmental Health Section

217 S. Ma

217 S. Main St.

in St.

Troy, NC 27371

(910) 572

(910) 572- - - - 8175 (office)

(910) 572

8175 (office)

(910) 571

(910) 571- - - - 0912 (fax)

0912 (fax)

OPERATION PERMIT RENEWAL APPLICATION

APPLICANT: ___________________________________ SYSTEM OWNER: ___________________________________

ADDRESS:

___________________________________

ADDRESS:

___________________________________

____________________________________

___________________________________

PHONE #:

____________________________________ PHONE #:

___________________________________

DIRECTIONS TO PROPERTY: ___________________________________________________________________________

________________________________________________________________________________________________________

SUBDIVISION: ____________________________ LOT #: __________

IS THIS SYSTEM OWNED BY A HOMEOWNER’S ASSOCIATION? ‫ ڤ‬YES

‫ ڤ‬NO

(IF YES, ATTACH A LIST OF THE BOARD OFFICERS, THEIR ADDRESSES, & PHONE #’S)

EXISTING OPERATION PERMIT #: _____________________ WHICH EXPIRES: _______________

TYPE OF WATER SUPPLY: ‫ ڤ‬PRIVATE WELL

‫ ڤ‬PUBLIC

‫ ڤ‬COMMUNITY WELL

‫ ڤ‬OTHER ____________

TYPE OF FACILITY: __________________________________ (e.g., Mobile Home Park, Industrial, School, Church, etc.)

(PLEASE COMPLETE ANY OF THE FOLLOWING THAT ARE APPLICABLE)

# EMPLOYEES: _____ # MOBILE HOME SPACES SERVED: _____ # BEDROOMS: _____ # DOG RUNS: _____

# CAR WASH BAYS: _____ #FOOD SERVICE FACILITIES: _____

# SEATS: _____

# CHURCH SEATS: _____

HOURS OF OPERATION: __________/__________

FREQUENCY OF EVENTS: _______________________________

DESCRIPTION OF FACILITY (INCLUDE ANY CHANGES SINCE ORIGINAL OPERATION PERMIT WAS

ISSUED):

________________________________________________________________________________________________________

IS THIS FACILITY UNDERGOING PROPOSED OR CURRENT CONSTRUCTION/EXPANSION?: ‫ ڤ‬YES

‫ ڤ‬NO

IF YES, EXPLAIN: ______________________________________________________________________________________

________________________________________________________________________________________________________

NAME OF CERTIFIED OPERATOR: ______________________________

PHONE #: ___________________________

CO’S ADDRESS: ________________________________________________

CONTRACT ATTACHED?: ‫ڤ‬YES ‫ڤ‬NO

_________________________________________________

(COPY OF CONTRACT WITH CERTIFIED OPERATOR REQUIRED PRIOR TO PERMIT RENEWAL)

THIS APPLICATION MUST BE SIGNED BY THE CURRENT OWNER OF THE SYSTEM OR THE OWNER’S

LEGAL REPRESENTATIVE (e.g., spouse, executor, power of attorney, etc.). ONLY ORIGINAL SIGNATURES CAN

BE ACCEPTED.

I have read this application and certify that the information provided herein is true, complete, and correct to the best of my

knowledge, and is given in good faith.

____________________________________

_________________________________

______________

Owner’s Signature

Title

Date

Application For Operation Permit Renewal Form - Montgomery County Health Department

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