Application For Operation Permit Renewal Form - Montgomery County Health Department

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Parcel ID#: ____________________________
Department Use Only
(available at Tax Office)
Application #: ____________________
Application Date: ____________________
Montgomery County Health Department
Montgomery County Health Department
Montgomery County Health Department
Montgomery County Health Department
Environmental Health Section
Environmental Health Section
Environmental Health Section
Environmental Health Section
217 S. Ma
217 S. Ma
217 S. Ma
217 S. Main St.
in St.
in St.
in St.
Troy, NC 27371
Troy, NC 27371
Troy, NC 27371
Troy, NC 27371
(910) 572
(910) 572- - - - 8175 (office)
(910) 572
(910) 572
8175 (office)
8175 (office)
8175 (office)
(910) 571
(910) 571
(910) 571
(910) 571- - - - 0912 (fax)
0912 (fax)
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

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