20078_Performance Auto_Well Abandonment Record_20200916

Orange County Health Department
_ 131 West Margaret Lane
[phone] MNITY
Suite 100
[phone] (FAX) -NT's TIT � AR01.1 A P.O. Box 8181
Hillsborough, NC 27278
WELL ABANDONMENT
PIN: 9799774983 Property Address: 111 COOPER ST
Application Date: 8/5/2020 9:24:56AM CHAPEL HILL
NC 27517
Permit Number: W20-0201 Township: CHAPEL HILL-7
Applicant: LG FORDHAM BLVD LLC Owner: CUNNINGHAM DANIEL
109 COOPER ST
CHAPEL HILL NC 27517
Phone: [phone] Phone: [phone]
Email: [e-mail] Email: [e-mail]
Description: 21/23 BL G UNIV HTS P4/17 Lot Size: 0.26 Acres
Permit issued: 08/06/2020 ENVIRONMENTAL HEALTH SPECIALIST: Tracey Langley
IMPORTANT INFORMATION:
The abandonment process of your well is complete. Please see the attached sketch for location of well(s).
APPROVED: Moira Beck
08/12/2020
PM_EG_EH_WeIlCertificateOfCompletion 2020.8
Report created:8/18/2020 4:39:OBPM

Orange County Health Department
Environmental Health Division
131 West Margaret Lane
(919)245=2360
Suite 100
[phone] (FAX) t [/, 01 P.O. Box 8181
www.orangecountync.gov lit€ R TH �;/�)���� jj�� Hillsborough, NC 27278
WELL PERMIT REQUESTFIELD LOG
Parcel Number : 9799774983
Application Date : 8/5/2020
Permit Number: W20-0201
Applicant Name : LG FORDHAM BLVD LLC
Address : 3500 MAPLE AVE STE 1600
DALLAS, TX 75219
Phone : [phone]
Email: [e-mail]
Property Description : 21/23 BL G UNIV HTS P4/17
Well Type: Municipal Water
Well Class : Abandonment
Well Type: � � I I�y,
Well Depth: , 1 ft.
Casing Diameter: � in.
Property Address : 111 COOPER ST
CHAPEL HILL, NC 27517
Township /Number :
owner Name:
CHAPEL HILL - 7
CUNNINGHAM DANIEL
Address :
109 COOPER ST
CHAPEL HILL, NC 27517
Phone :
Email:
[phone]
[e-mail]
Lot size :
0.26 Acres
Sewage Disposal : Sewer System
EXISTING WELL DATA
Well Use: A V1 YM ► `� � � �( VSQ/
Well Diameter: U inidddit•
Casing Depth: V,VWW rl ft. Static Water Level:V±
WELL ABANDONMENT INSPECTION
Chlorinated: 7J71e � �� Ammuu � o�L
10 GPS'd by OCHD Latitude pN
Type of Material used in abandonment: YU (At C (M Vlf 6t
_
Groutwithin I ft qj/and surfave
® Pump, piping any obstructions
removed from well
Longitude
W
How
emplaced: YJ�yY`
Amount/# Bags
© NC Licensed, OCHD Registered Well Contractor present OR � Abandonment by Owner
,,,ante lG11�W1 D�YyLV� NCRegAlrarinntt 33ZZ
El Well log received (GW=30)
NOTES
AS-DUILT LOCATION OF \VELLTO DE INDICATED ON PElih11T SITE PLAN
YET TO DO
FINAL INSPECTION COMPLETED
ADDITIONAL UTAGRA01lNOTES ON UACK
z
PM_OC_EH_We1lFieldLog 2020.8
Report created : 8/1112020 10:09:46AM

WELL A
This form can be
DONMENT REC(
for single or multiple wells
Por Internal Use ONLY:
1. Well Contractor Information:
Lawrence D. Opper
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC 3322-A
NC Well Contractor Certification Number
Regional Probing Services
company Name Variance #$WWM1061
2. Well Construction Permit #: Orange County abandon.Permit #W20-0201
List rill applicable well construction permits (i.e. C•ounry, Slate, Variance, etc.) if known
3. A1'cIl use (check well use):
\1'atcr Supply Well:
❑Agricultural
❑Municipal/Public
❑Geothermal (Heating/Cooling Supply)
Residential Water Supply (single)
❑industrial/Commercial
❑Residential Water Supply (shared)
❑Irrigation
Nun-NVater Supply Well:
❑Monitoring
❑Recovery
Injection AVell:
❑Aquifer Recharge
❑Groundwater Remediation
❑Aquifer Storage and Recovery
❑Salinity Barrier
❑Aquifer Test
❑Stonnwater Drainage
❑Experimental Technology
❑Subsidence Control
[]Geothermal (Closed Loop)
❑Tracer
❑Geothermal (lleating/Cooling Return)
❑Other (explain under 7g)
a. Date,veu(s) abaminnedt 8/6/2020
Sa. Well location:
Daniel Cunningham
Facility/Owner Name
11 I Cooper Street, Chapel Hill
Physical Address, City, and Zip
Orange
County
Facility ID# (ifapplicable)
9799-77-4983
Parcel Identcation No. (PIN)
56. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(irwell field, one lot/long is suilicienQ
350942714 N 79.008433
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
,4tmd, well consn•uctian record(.+) if m•ailnble. For m+duple it jection a• non -+rater supply
wells Or\'/.I'with the.rnme con.rnzrction"abandonmen�,Yon can.rubmit one jornr.
6a. Well ID0: Supply Well
6b.'I'otal well depth: 77
6c. Borehole diameter: well �nn
1VELL ABANDONMENT DETAILS
7a. Number of wells being abandoned: 1
!•br uadtipOtt injection • non -water supply
cans iruction/abaulonrnew, you can submit one farm.
well
OrA4,1' +Jilin 1 e same
7b. Approximate volume of water remaining in well(s): 0 (gal.)
fOR WATY ER SUPPL\FELLS ONLY:
7c. Type of disinfectant used: 65% Calcium Hypochlorite
7d. Amount of disinfectant used: 60Z
7e. Scaling materials used (check all that apply):
Neat Cement Grout ❑ Bentonite Chips or Pellets
❑ Sand Cement Grout El Dry Clay
El Grout ❑ Drill Cuttings
El Grout ❑ Gravel
El Slurry ❑ Other (explain under 7g)
7f. Por each material selected above, provide amount of materials used:
Neat Cement Grout: 21 gal
7g. Provide a brief description of the abandonment procedure: -
The well had an pre-existing obstruction or formation collapse at 14 Ti.
The well was de -watered and disinfected prior to abandonment.
Neat Cement grout slurry was emplaced filling the well to the ground surface
8. Certification:
Lawrence Opper
8/11 /2020
Signahwe of Certified Well Contractor or Well Owner Date
BY sighing this form, I herherebycertifjr that the iwell(s) was (were) abandoned ita
accordance with ISA NCAC O2C .0/00 or 2C .0200 Well Consh•uction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional \veil site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. far All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
t. )
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 276994617
10b. for Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
°) abandonment to the following:
6t1. Water level below ground surface: � 14
6e. Outer casing length (if known):
6f, hater casing/tubing length (if known):
6g. Screen length (if known):(ft.)
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
lOc. for Water Supply &Infection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health deparhnent of the county
where abandoned.
Bonn G\\'-30 North Carolina Department of Environment and Natural Resources — Division of Water Quality Revised March 2013
7f. Por each material selected above, provide amount of materials used:
Neat Cement Grout: 21 gal
7g. Provide a brief description of the abandonment procedure: -
The well had an pre-existing obstruction or formation collapse at 14 Ti.
The well was de -watered and disinfected prior to abandonment.
Neat Cement grout slurry was emplaced filling the well to the ground surface
8. Certification:
Lawrence Opper
8/11 /2020
Signahwe of Certified Well Contractor or Well Owner Date
BY sighing this form, I herherebycertifjr that the iwell(s) was (were) abandoned ita
accordance with ISA NCAC O2C .0/00 or 2C .0200 Well Consh•uction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional \veil site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. far All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
t. )
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 276994617
10b. for Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
°) abandonment to the following:
6t1. Water level below ground surface: � 14
6e. Outer casing length (if known):
6f, hater casing/tubing length (if known):
6g. Screen length (if known):(ft.)
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
lOc. for Water Supply &Infection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health deparhnent of the county
where abandoned.
Bonn G\\'-30 North Carolina Department of Environment and Natural Resources — Division of Water Quality Revised March 2013

DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC HEALTH
ROY COOPER
GOVERNOR
Onsite Water Protection Branch
August 11, 2020
Daniel C�mningham
109 Cooper St.
Chapel Hill, NC 27517
RE: Approval WWM1061
Abandon Water Supply Well Without Removal of Debris
Rule 15A NCAC 2C .0113
111 Cooper St., Chapel Hill, NC
Dear Ash•. Cunningham:
MANDY COHEN, MD, MPH
SECRETARY
MARK BENTON
DIRECTOR
On August 10, 2020, the On -site Water Protection Section received your request to approve the abandonment of a water supply well
that currently has an obstruction inside the casing, and removal of this material is not achievable. The approval request is for the
abandonment of one (1) water supply well at 1 ll Cooper St., Chapel Hill, NC. In your request you indicated that due to the depth of
the material and the inability to remove the material without causing further damage, removal of the debris is not a viable option.
Based upon available information, you are approved to abandon this well without removing any material and by pouring a neat cement
grout into the portion of the well containing the obstruction and then properly abandoning the remainder of the well to land surface, in
conformity with the requirements of 15A NCAC 02C .0113. A copy of this approval should be attached to the required Well
Abandonment Record (GW-30) as well as the county well permit at such time that it is issued.
The approval of this variance does not affect any of the other requirements or limitations of the Well Construction Standards,
including but not limited to the requirements in 15A NCAC 2C .0113(b) to repair or to abandon any well which acts as a source or
channel for the migration of contamination or to your responsibility to comply with any other applicable Federal, State, or local laws
or regulations. Furthermore, the granting of this approval is for the well abandonment only, and in no way relieves the owner or agent
from other requirements of the North Carolina Well Construction Standards, or any other applicable law, rule, or regulation that may
be regulated by other agencies, nor does it imply sufficient water quality.
If you have any questions regarding this variance, please contact Wilson Mize at (919)-270-9665
Sincerely,
Wilson Mize R.E.H.S.
WWW.NCDHHS.GOV
TEL [phone] •FAX [phone]
LOCATION: 5605 SIX FORKS RD •RALEIGH, NC 27609
MAILING ADDRESS: 1642 MAIL SERVICE CENTER • RALEIGH, NC 27699-1642
AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
VARIANCE APPLICATION FOR 2C .0100 WELL CONSTRUCTION STANDARDS:
PRIVATE DRINKING WATER WELLS UNDER 15A NCAC 02C .0300
WATER SUPPLY WELLS UNDER 15A NCAC 02C .0107
Alt water supply wells not considered 'Private Drinking Water Wells" and including irrigation, industrial, and commercial wells.
WELLS OTHER THAN WATER SUPPLY UNDER i5A NCAC 02C .0108
Grcloding monitoring and recovery wells.
Prin! clearly or type inJorntnrton. �ttegtnte suo�nuuu� war �r � c,... •.�•• ••� •••��•••r•�•-•
DATE: August 10 20 20 PERMIT NO.: W20-0201 (to be completed by DWQ/DPH)
A. WELL OWNER —For single family residences list the property owner(s). For all others, list name of the business,
organization, or government agency and person delegated signature authority:
Daniel Cunningham
Mailing Address: 109 Cooper St
City: Chapel Hill State: NC Zip Code:27517 County: Orange
Day Tele No.: [phone] Cell No.:
EMAIL Address: [e-mail] Fax No.:
Be PHYSICAL LOCATION OF WELL SITE
(1) Parcel Identification Number (PIN) of well site: 9799-77-4983
County: Orange
(2) Physical Address (if different than mailing address): 111 Cooper St
City: Chapel Hill State: NC Zip Code: 27517
Co WELL DRILLER INFORMATION (if known)
Well Drilling Contractor's Name: Lawrence Do Opper
NC Well Drilling Contractor Certification No.: 3322-A
Company Name: Regional Probing Services Contact Person:
City: Wake Forest State: NC Zip Code:27588 County: Wake
Day Tele No.: [phone] Cell No.:[phone]
EMAIL Address: [e-mail] Fax No.:
Fonn GW-22V Page 1 Revised February 2013

U, REASON FOR VARIANCE REQUEST — Include type of well(s) to be constructed; rule for which the variance is
being requested; description of how the alternate construction will not endanger human health and welfare and the
environment; and reason why construction and/or operation in accordance with the standards is not technically feasible
and/or provides equal or better protection of the groundwater.
Well Abandonment:
Due to the unidentified obstruction in the well at fourteen feet, the use of bentonite chips could not be
used. The well is a total of seventy-seven feet deep and we can not ensure that the hole is properly
sealed using bentonite. Therefore, we are using a neat cement mix which is more viscous to fill in any
holes or gaps around or beneath the obstruction.
E. ATTACHMENTS --Provide the following information as attachments to this application:
(i) A map showing general location of the property (including road names, NC State Route Number, distances,
any key landmarks, etc.) sufficient for finding the well location.
(2) Detailed site map with scale showing location of proposed well relevant to septic system(s), building.
foundations, property lines, water bodies, potential sources of contamination, other wells, etc.
(3) Submit a copy of the local well permit application and site evaluation map (if applicable).
(4) Any other information relevant to the variance request such as a well construction diagram showing proposed
well liner or atypical construction materials/methods.
F. OTHER MINIMUM CONSTRUCTION REQUIREMENTS
For water supply wells, approval of a variance will require that additional construction requirements beyond those
specified in 15A NCAC 02C .0107 be met. Minimum additional construction requirements for Coastal Plain and
Piedmont and Mountain region wells are referenced on Attachments A and B on pages 4 and 5 of this application.
Approval of a variance will not be considered in cases where the specified minimum additional construction
requirements cannot be met.
G. SIGNATURES
'ell Construction (typically the well driller)
well abandonment)
Lawrence D. Opper
Print or Type full Name of Person Responsible for Well Construction
(typically the well driller)
Signature of County Environmental Health Specialist
Moira Beck, REHS
Print or Type roll Name of County Environmental Health Specialist
Per /SA NCAC 02C .0118 the Secretary of the Division of Water Quality or the Division of Public Health stay require
submittal of infor•matiat deemed necessary to make a decision on the variance, may imposeriaconditions as part riaof the
decision, and shall respond in writing to the request within 30 days of receipt of the vance request, A vance
applicant who is dissatisfied with the decision of the Director may commence a contested terse by filing a petition as
described in G.S. 150B-23 within 60 days after receipt of the decision.
Form G4V-22V Page 2 Revised February 2013

He SUBMITTAL INSTRUCTIONS
(1) For the following types of water supply wells onl :
(a) Private Drinking Water Wells under 15A NCAC 02C .0300
(b) Irrigation Wells underl5A NCAC .02C .0107 with a designed capacity of less than 100,000 gallons per day
and located on the same property as an on -site wastewater system permitted by a local health department.
Prior to submittal of the variance for these types of wells, please contact your regional environmental health
specialist by visiting: http://chs.nepLiblichealth.coiiVcontacts.htm
Submit one copy of the completed variance application to:
North Carolina Department of Health and Human Services
Division of Public Health — Environmental Health Section
On -Site Water Protection Branch
1632 Mail Service Center
Raleigh, North Carolina 276994632
(2) For the following types of wells only:
(a) All Water Supply Wells under ISA NCAC 02C .0107 other than the ones listed under (1) above
(b) Wells Other than Water Supply under 15A NCAC 02C .0108. If these wells are to be constructed on property
not owned by the well owner or applicant, please also attach and submit a completed Application to Construct
a Monitoring or Recovery Well System (GW-22MR) found on our website at:
http•//portal ncdenr org/web/Nvq/aps/gwpro/pennit-applications
Submit one copy of the completed
variance application to the Division
oI Water Quality Regional Office
serving the area in which the well
will be located:
Asheville Regional Oftice
2090 U.S. Highway 70
Swannanoa, NC 28778
Telephone: [phone]
Fax: [phone]
Fayetteville Regional Office
225 Green Sheet, Suite 714
Fayetteville, NC 28301-5043
Telephone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue,
Suite 301
Mooresville, NC 28115
Telephone: [phone]
Fax: [phone]
Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27699-1628
Telephone: [phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Telephone: [phone]
Fax: [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wihnington, NC 28405
Telephone: [phone]
Fax:[phone]
ston-Salem Regional
Office
585 Waughtowm Street
Winston-Salem, NC 27107-2241
Phone: [phone]
Fax:[phone]
Form GW-22V Page 3 Revised February 2013

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Orange County Health Department
Environmental Health Division
131 West Margaret Lane
�- -y
[phone] Suite 100
(919) 644=3006 (FAX) N 1 k, ,'k � I, P.O. Box 8181
www.orangecountync.gov ORTI I C;AROLINA Hillsborough, NC 27278
AtSANUUNIVILN 1 rCKIVII I
Parcel Number : 9799774983 Property Description : 21/23 BL G UNIV HTS P4/17
Application Date : 08/05/2020 Property Address : 111 COOPER ST
Permit Number: W20-0201 CHAPEL HILL, NC 27517
Applicant : LG FORDHAM BLVD LLC
Address : 3500 MAPLE AVE STE 1600
DALLAS, TX 75219
Phone : [phone]
Email : [e-mail]
Well Type :Municipal Water
Well Class : Abandonment
Comments /Conditions
Condition
Description
ISSUED 08l06l2020 � a & 14Gy � �� EXPIRES : 08/06/2025
Tracey Langley
ENVIRONMENTAL HEALTH SPECIALIST
Owner:
Address: 109 COOPER ST
CHAPEL HILL, NC 27517
Phone: [phone]
Email: [e-mail]
Lot Size : 0.26
Sewage Disposal : Sewer System
Comment
The WELL SHALL BE ABANDONED IN ACCORDANCE WITH:
Orange County Groundwater Protection Rules as adopted by the Orange County Board of Health and the NC Well Construction Standards , as
applicable.
1. The applicant or well contractor shall contact the Orange County Health Department to provide notification of intent to permanently abandon
any well other than a monitoring well and include the location, permit number, and anticipated time for abandonment of each private drinking
water well.
2. The well abandonment must be inspected by OCHD.
3. Upon completion of a permanent well abandonment, the Orange County Health Department shall provide a written certification on the well
abandonment permit hat a well abandonment inspection was completed and that the abandonment is in compliance with these Rules. When
the Orange County Health Department opts to not inspect the permanent abandonment process, the well contractor shall provide written
certification to the Orange County Health Department that the well has been abandoned in compliance with these Rules. A completed Well
Abandonment Record form GW-30 stating the well was abandoned in compliance with the rules of this Section shall serve as the well
contractor's abandonment certification.
4. After the abandonment is completed, some settling of the abandonment material may take place. If it has settled substantially, please call
the well contractor.
rpl_PM_O
C_EH_We
IIPe rmil
2020.8
Report
creased :
8/6/2020 9:15a0AM

I®
111 Cooper St.
Chapel Hill, NC 27517
Well Abandonment
W2O-O2O1
Drilled well out of use
Approximate Depth 77'
Obstruction at 14'
Currently using municipal
water and sewer.
Location of
Existine Well
Orange Gaunty Envir©nmental Health
This map contains parcels prepared for the inventory of seat property within Orange County, and is compiled from
recorded deeds, plats and other public records and data. Users of this map are hereby notified that the aforementioned
public primary information sources should be consulted for verification of the information contained on this map. The
county and its mapping companies assume no legal responsibility for the information on this map.
1 inch = 30 feet

Orange County Environmental Health
PO Box 8181, 131 W Margaret Ln, Hillsborough, NC 27278
or
APPLICANT* LG Fordham Blvd LLC
ADDRESS 3500 Maple Avenue, Ste 1600
Dallas, TX 75219
PROPERTY OWNER* Daniel Cunningham
ADDRESS 109 Cooper Street
Chapel Hill, NC 27517
EMAIL EHoward a�Geosyntec.eom EMAIL* [e-mail]
DAYTIME PHONE NUMBER* (919)2644745 DAYTIME PHONE` [phone]
SITE ADDRESS: 111 Cooper Street, Chapel Hill, NC 27517
DIRECTIONS t LOCATION* Well is located in front yard, between driveway and front door
PINS 9799-77-4983
*REQUIRED
LOT SIDE 0.26 A SUBDIVISION /LOT#
❑ NEW SEPTIC ❑NEW WELL
❑ EXPANSION OF SEPTIC SYSTEM (I.E. ADDING BEDROOM)
❑ SEPTIC SYSTEM REPAIR ❑ WELL REPAIR
❑ EXISTING SEPTIC AUTHORIZATION OR CHANGE OF USE
❑ PERMIT REVISION; PERMIT#
WELLABANDONMENT ❑ SEPTIC SYSTEM ABANDONMENT
❑SUBDIVISION/RECOMBINATION OF PROPERTY
❑ WELL OR SEPTIC PERMIT RENEWAL: PERMIT #
PROJECT DESCRIPTION (BE SPECIFIC) *REQUIRED:
Abandonment Of inactive water supply well via bentonite chi
is approximat
- well ely 77' dee
SINGLE FAMILY DWELLING *Number of Bedrooms: 2 Number of occupants: 3
❑MULTI FAMILY: APARTMENT / GUEST HOUSE *Number of Bedrooms: Number of occupants:
*REQUIRED
❑BUSINESS/OTHER DOCUMENTATION OF TYPE, USAGE, NUMBER OF USERS/ STAFF WILL BE REQUIRED,
ATER SUPPLY PLEASE CHECK IF APPLICABLE *REQUESTED SYSTEM MATERIAL
PUBLIC ❑BASEMENT WITH PLUMBING. ❑ NO PREFERENCE
❑ PRIVATE WELL ❑ WASTEWATER OTHER THAN SEWAGE GENERATED ❑ CONVENTIONAL ONLY
❑ COMMUNITY WELL ❑ PROPERTY CONTAINS DESIGNATED WETLANDS ❑ ACCEPTED MATERIALS
❑ OTHER ❑ SITE IS SUBJECT TO APPROVAL BY OTHER AGENCY ❑ OTHER
❑ GARBAGE DISPOSAL
*REQUIRED ❑ WATER SOFTENER `REQUIRED FOR IP/CA
INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED. THE FOLLOWING IS REQUIRED.
❑SITE ASSESSMENT: A site assessment must be obtained from the Planning Department with jurisdiction over
the property
❑SITE PLAN DRAWN TO SCALE:
a. Existing and proposed property lines, easements, rights -of -way; and buffers with measurements;
b. Location of all proposed structures, driveways, additions, other future improvements with
measurement of the structures and measures to two property lines (minimum);
c. Known sources of contamination (septic drain fields, animal lots, fuel tanks, old wells);
CIFLOOR PLAN (not required for Well Permits or Residential Improvement Permits, other conditions apply for
commercial projects)
Please read before signing. Acknowledgment: This application has been signed by the current OWNER of the
property or the OWNER'S LEGAL. REPRESENTATIVE (documentation required) who has entered into a contract
or lease with the owner and who may legally represent the property owner in the transactions regarding the
property. Contact this office regarding digital signatures. 1, the undersigned, am the property OWNER or the
LEGAL REPRESENTATIVE. By signing this application, I grant the Orange County Health Department,
Environmental Health Division, right of entry to the property to perform the service(s) requested,
OWNERIREP:
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PING FEES 20194020:
IMPROVEMENT PERMIT UP TO 600 GPD $485
IMPROVEMENT PERMIT REISSUE/ REVISION/ RENEWAL $175
IN -OFFICE REVISION OF IMPROVEMENT PERMIT $35
EXPANSION OF EXISTING SYSTEM IP �$485
SUBDIVISION/ RECOMBINATION $485
Up to two acres is evaluated. Sites where rock greater than 4" in diameter is prevalent will
require evaluation by backhoe pit.
Any changes to the site plan, floor plan, or intended use shall require a new application and
additional fees. All projects with a design flow in excess of 600 GPD require additional fees.
All projects with a design flow in excess of 600 GPD, non-residential projects, and subdivisions
require that the applicant contract with a backhoe operator to dig pits on the site. Subdivisions
and recombination of properties require at least the concept plan approval or plat prepared by
CONSTRUCTION AUTHORIZATION UP TO 600 GPD NEW OR EXP $360
CONSTRUCTION AUTHORIZATION REISSUE/REVISION/ RENEWAL $175
IN -OFFICE REVISION OF CONSTRUCTION AUTHORIZATION $35
CONSTRUCTION AUTHORIZATION- REPAIR $0
Any changes to the site plan, floor plan, or intended use shall require a new application and
additional fees. All oroiects with a design flow in excess of 600 GPD require additional fees.
EXISTING SYSTEM AUTHORIZATION NO CHANGE IN FLOW $175
IN -OFFICE ESA WHERE NO SITE VISIT IS REQUIRED $35
MOBILE HOME PARK SPACE RECONNECTION AUTHORIZATION $105
SEPTIC SYSTEM ABANDONMENT $0
Certain conditions, such as prolonged vacancy or site specific concerns, can require parts of
the septic to be uncovered, the tank to be pumped,and property lines to be surveyed.
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WELL PERMIT REPLACEMENT
WELL PERMIT -IRRIGATION OR;�E'OTI�Eh AL
WELL PERMIT- REPAIR OR ABANDONME ,%1T +BACTERIA SAMPLE.
Well permit -fee- includes one set of compliance water sampling for water supply wells after
constnaction. If the well will serve more than one purpose (i.e. dunking water: supply AND
geothermal), indicate on PROJECT DESCRIPTION.
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RPREPARING FOR THE SITE EVALUATION OR SITE VISIT*
Improvement Permits forsingle-family dwellings on recorded properties and some Existin System Authorizations
and Well Permits can be evaluated and visited without making appointments.
❑Verify that the email and phone submitted are the best ways to reach the APPLICANT,
❑All proposed structures must be staked.
❑Property lines and corners must be clearly marked and accessible, if property lines cannot be verified, it will be
necessary for the property to be surveyed before a determination can be made.
GTrim thick vegetation. The area may need to be "bush -hogged" or thinned out. Do not grade or excavate
potential soil areas, as it is possible to damage sites beyond use,
"REQUIRED. Failure to prepare the site may cause long delays in permitting or may result in a Notice of
lncompletian
Please read before signing.
Acknowledgment: 1, the undersigned, understand that I am. the responsible party for making the site accessible for
evaluation, permitting, and i pection purposes. Records, flags, and ribbon are available upon request.
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