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HomeMy WebLinkAboutRBPR-07-2015-21860.TIFApplicant THIS IS NOT A PERMIT Case # RBPR-07-201 5-21860 CATAWBA COUNTY HEALTH DEPARTMENT PLAN REVIEW APPLICATION FOR ENVIRONMENTAL SERVICES Residential Building Plan Review - Building Alteration IMPROVEMENT -A UTHCONST - EXPANSION SAME AS OWNER, , Owner DUSTIN OTTERBERG, 1129 ROLLING GREEN DR, NEWTON NC 28658 C:828_2341210 NAME TO APPEAR ON PERMIT Dustin Otterberg SITE ADDRESS: 1129 ROLLING GREEN DR, NEWTON NC 28658 PIN # 372013242766 NAME of SUBDIVISION: ROLLING GREEN Lot # PT 6 Section/Block PROPERTY SIZE: Square Feet Acres 421 DIRECTIONS: Startown RD, Turn Sandy Ford RD PRIMARY CONTACT: Owner SEWER TYPE: Septic Tank GALLONS PER DAY: 720 WATER SUPPLY : Private Well DESCRIBE WORK: Finish existing unfinished basement - 2 bedrooms, 2 full baths, kitchenette SITE INFORMATION Do any of the following apply to the property for which this application is applied? If the answer to any of the questions below is "YES', then supporting documentation is required: Does this site contain any jurisdictional wetlands? No Does this site contain any existing wastewater systems? Yes Is any of the wastewater going to be generated on the site other than domestic sewage? No Is the site subject to approval by any other public agency? Yes Are there any easements or right-of-ways on this property? No APPLICATION FOR: Existing Structure STRUCTURE TYPE: PRIMARY RESIDENCE FACILITY TYPE: Single Family Residence OTHER DESCRIPTION: DESCRIPTION OF Single Family Dwelling EXISTING STRUCTURES ON SITE (IF ANY DIM EXISTING STRUCTURE: 100x82 NUMBER OF EXISTING BEDROOMS: 4 # OF OCCUPANTS: 4 PROPOSED CONSTRUCTION # OF NEW BEDROOMS:: 2 BASEMENT? Yes BASEMENT FIXTURES? PLUMBING REQUIRED? Desired system types (Improvement Permit or Authorization to Construct): ACCEPTED: ALTERNATIVE: CONVENTIONAL: OTHER: INNOVATIVE: ANY YES Other described. E9 - chapphcat mn 07/01/2015 15 43 Page I of 4 SpA CATAWBA COUNTY Case # RBPR-07-2015-21860 Public Health Department Subdivision ROLLING GREEN Environmental Health Division P1N# 372013242766 PO Bos 389. 100-A Southwest Blvd, Newton. NC 28658 NAME ON PERMIT: ( DUSTIN OTTERBERG), 1129 ROLLING GREEN DR, NEWTON NC 28658 ( Dustin Otterberg) Site Address: 1129 ROLLING GREEN DR, NEWTON NC 28658 Property Size: Square Feet Acres 4'21 Directions: Startown RD, Turn Sandy Ford RD Improvement Permits issued as a result of this information are valid for 5 years or may be non -expiring under certain specified conditions. An Authorization to Construct issued by this department is valid for (5) five years from the date issued and is not transferable; Improvement Permits and Well Permits are transferrable. Permits may be revoked if the information on this application, site plans or intended use changes for the proposed facility. I have read this application and certify that the information provided herein is true, complete an correct Authorized count and state officials are granted right of entry to conduct n essary inspections to determine compliance with appliZacc s ntl rules. I under n t am solely responsible for the proper identification and I belin of all pro erty lines and corners and making the si so that a c an be performed Date: %( 1r)01� Signature of ApplicaAn Environmental Health Specialist will contact yo5 orking d s o pbeation date. If you need further information or assistance please call 828-466-7291 AREA2 FEENAME DATE FEEAMOUNT Authorization to Construct Fee (New/Expansion) 07/01/2015 $500.00 Fee Improvement Permit Fee 07/01/2015 SI50.00 TOTAL FEES S650.00 FEES ARE NON-REFUNDABLE ONCE A SITE VISIT IS MADE OR WORK ON A PLAN REVIEW HAS COMMENCED SYSTEM REDESIGN AND/OR RETRIP WILL INCUR AN ADDITIONAL CHARGE (SEE FEE SCHEDULE) E9 - chapphiauon 07/01/2015 15:43 Page 2 of C / TA BA THIS IS NOTA PEn41T ` -f6w — OrA— a0 is 4 0 DO ctL,L+xTs CATAWBA COUNTY HEALTH DEPARTMENT R.a,�a„erg Application for Environmental Service Page 1 Improvement Permit V Authorization to Construct 2( Septic Repair ❑ .Septic Malfunction ❑ Septic Expansion ® New Well Permit ❑ Replacement Well ❑ Well Abandonment ❑ Well Repair ❑ Existing System Inspection (Pre -Approval Required) ❑ Application is for New Construction ❑ Existing Facility ❑ Property Address If a9 ]tiU nct J J�7etn JJV. Subdivision Lot # 4An5 Gr1r--et- - Acres Section/Bloc Phasc Driving Direction to Property A1- //I,KK 0V. 5a^y Aaej 9-d_ qo 314 4 -w -r\ KF� ay. 20/l, s �nre�v i�r. - �%I u / of C rc% to oPi4 iv h cr� in tie NAME TO APPEAR ON PERMIT? XOwner ❑ Applicant ❑ Contractor Applicant Contact Information Name T/ N Address- /yam y ZU Phone Owner Contact Information Name Address I Phone OTTER A�R� �& //,/& G 12 GF_ N Contractor Contact Information Name Address Phone sl i3nvi2. D2. CcIIPhone 7,), a3�1 �oZyO Cell Phone I Cell Phone WHO WILL BE THE PRIMARY CONTACT? B Owner ❑ Applicant ❑ Contractor Description of Existing Structures on / Site B,i Ok. 5 W'fL # of Bedrooms *j 14/Structure Dimensiot OD- j # of Occupants 4/ Basement Z Yes El No Basement Fixtures” Yes The Applicant shall notify the local health department upon submittal of this application if any of the following apply to the property in question. If the answer to any question is "yes", applicant must attach supporting documentation. ® Yes WNo Does the site contain any jurisdictional wetlands? bpd L ® Yes ® No Does the site contain any existing wastewater systems? ' 0 Yes 119 No Is any wastewater going to be generated on the site other than domestic sewage? Yes 'o Is the site subject to approval by any other public agency? '0 Yes O No Are there any easements or right of ways on this property? Describe Existing water supply in use F�L Individual Well ❑ Community Well ❑ Semi -Public Well ❑ County/City/Township Water Line Is a public water supply available? ** ❑ Yes ❑ No If applying for an Improvement Permit or Authorization to Construct, Please Indicate Desired System Type(s): (systems can be ranked in order of your preference) 0 Accepted 0 Alternative �Convcntiona12 El Innovative 0 Other YAny Catawba County Environmental Health Parcel: 372013242766, 1129 ROLLING GREEN lin=150ft DR NEWTON, 28658 This map/report product was prepared from the Catawba County, NC Geospatial Information Services. Catawba County has made substantial efforts to ensure the accuracy of location and labeling information contained on this map or data on this report Catawba County promotes and recommends the independent verification of any data contained on this map/report product by the user. The County of Catawba, its employees, agents, and personnel, disclaim, and shall not be held liable for any and all damages, loss or liability, whether direct, indirect or consequential which arises or may arise from this map/report product or the use thereof by any person or entity. Copyright 2014 Catawba County NC 07/01/2015 cCAT,+ta ]' k THIS IS NOTA PERN4IT v}L1\r .CiVV F� CATAWBA COUNTY HEALTH DEPARTMENT Application for Environmental Services Page 2 Proposed Facility Type Primary Residence ❑ New Residence _ Ad ti9n to esidence of New Bedrooms *t Project Description 9" k UN ¢1�.5 J 4tH e» Structure Dimensions /Cbz X A10 ' # of Occupants "t Basement P Yes ❑ No Basement Fixtures O Yes ®No ❑ Accessory Structure(s) Describe # of New Bedrooms * i if applicable Structure Dimensions # of Occupants Accessory Dwelling ❑ Yes ❑ No Plumbing ❑ Yes ❑ No Describe Plumbing Needed ❑ Multi -Family Residence # Units Total # Bedrooms *j' ❑ Food Service Specify Type # Seats # Employees per Shift #Bedrooms per Unit*'l Structure Dimensions Floor Space -Entire Food Service Facility (Sq Ft) ❑ Business Specific Type of Business # of Employees per Shift ❑ Other Facility Type Specify # of Shifts Dining Area (Sq. Ft.) Retail Floor Space # of Shifts If Church # of Seats Kitchen ❑ Yes ❑ No If Daycare Specify Occupancy Application for Well Construction/Abandonment/Repair Proposed Well Type ❑ Individual Well ❑ Semi -Public Well ❑ Community Well Abandonment Type ❑ Drilled ❑ Bored ❑ Dug ❑ Unknown Well Repair Requested ❑ Yes ❑ No Describe Calculated Design Flow, Commercial -r Additional information may be required to determine design flow from certain facilities. This value will be determined during consultation with on-site staff. *Any room that will be intended for sleeping at the time of construction or for future consideration should be noted as a bedroom and counted on all applications. The number of bedrooms will be confirmed by rooms identified on house plans as a bedroom at the time of building permit issuance. This may prevent the need for septic system size increase in the future. t If structure is plumbed but no bedrooms, calculated design flow is required. ** If No, a well permit must be issued with the Authorization to Construct. SYSTEM REDESIGN AND/OR RETRIP WILL INCUR AN ADDITIONAL CHARGE (SEE FEE SCHEDULE) Improvement Permits issued as a result of this information are valid for 5 years or may be non -expiring under certain specified conditions. An Authorization to Construct issued by this department is valid for (5) five years from the date issued and is not transferable; Improvement Permits and Well Permits are transferrable. Permits may be revoked if the information on this application, site plans or intended use changes for the proposed facility. I have read this application and certify that the information provided herein is true, complete and correct. Authorized county and state officials are granted right of entry to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am solely responsible for the proper identification and labeling of all property tines and comers and making the site accessible so that a complete site evaluation can be performed. Signature of Owner or Agen jj , Date V v Printed Name of Owner or Agent ST/NT T. Q ry F (Z yEt2 tSt Parcel Report Parcel Report- Catawba County NC Parcel Information: Parcel ID: 372013242766 Parcel Address: 1129 ROLLING GREEN DR City: NEWTON, 28658 LRK(REID): 41831 Deed Book/Page: 2693/1487 Subdivision: ROLLING GREEN Lots/Block: PT 6/ Last Sale: $55,000 on 2005-09-15 Plat Book/Page: 19/334 Legal: LOT PT 6 PT6 PL19-333 ROLLING GREE PL 19-334 Calculated Acreage: 4.210 Tax Map: 087N 01009 Township: NEWTON State Road #: 2902 Tax/Value Information: Tax Rates(pdf) City Tax District: All in County County Fire District: HICKORY RURAL Building(s) Value: $580,100 Land Value: $59,500 Assessed Total Value: $639,600 Year Built/Remodeled: 2008/ Current Tax Bill Miscellaneous: Building Permits for this parcel. Building Details W aterShed: Voter Precinct: P34 Parcel Report Data Descriptions List all Owners Deed History Report Owner Information: Owner: OTTERBERG DUSTIN J Owner2: OTTERBERG SHANI A Address: 1129 ROLLING GREEN DR Address2: City: NEWTON State/Zip: NC 28658-9269 School Information: School District: COUNTY Elementary School: STARTOWN Middle School: MAIDEN High School: MAIDEN School Map Zoning Information: Zoning District: COUNTY Zoningl: R-20 Zoning2: Zoning31: Zoning Overlay: Small Area: STARTOWN Split Zoning Districts: / Zoning Agency Phone Numbers Firm Panel Date: 2007-09-05 Firm Panel #: 3710372000J 2010 Census Block: 1049 2010 Census Tract: 011701 Agricultural District: Assessment Report Page 1 of 1 This map/report product was prepared from the Catawba County, NC Geospatnal Information services. Catawba County has made substantial efforts to ensure the accuracy of location and labeling information contained on this map or data on this report Catawba County promotes and recommends the independent verification of any data contained on this map/report product by the user. The County of Catawba, its employees, agents, and personnel, disclaim, and shall not be held liable for any and all damages, loss or liability, whether direct, indirect or consequential which arises or may arise from this map/report product or the use thereof by any person or entity © 2015, Catawba County Government, North Carolina. All rights reserved. uw) — PU rp ( 90 http://gis.cataxvbacount),nc.gov/nomap/parcel_report.php?key=372013242766&typ=P 7/1/2015 CATAWBA COUNTY HEALTH DEPARTMENT /00s" / Telephone: (828) 465-8270 TDD: (828) 465-8200 WLS # a JD5 — ()()91-0 Improvement Permit ✓ AC Repair Permit. Operation Permit._ System Type_ Well Permit. Replacement Well Owmer/Agent —0 )0+4-0.rV-'7rr Phone Address Od Alo .t7 jVr-93 4)'A SubdivisionQollt& C?f22n Section/Block/Phase-� Lot# b Lot Size l(.al Directions: k)t 54-arfOWA kc) 1+ SCAB i urd�fCa Q1 Kollin &MtA- `;-o eni ,.0 r UI-Ja-.,tinc. Property Address 1\10 .if -on, Facility: House Mobile Home Business_Multi-family_ Other: Pin Number 3-13013a'fiti766 Other . Zoning Approval # # Bedrooms # Seats # Employees . Application Rate , 3 GPD Flow Ljf ,Q Hot Tub or Spa yes/no Special Fixtures Basemen yes o - 100% Repaa r Area �J yeso Basement Plumbin o Water p-pT Well f/ Public_ Semi -Public_ Type of System: Trench \/ Bed_ Pump_ Pump/Panel _ Panel_ LPP Other asclio Red - Se tic Tank Size t�0 Septic Ia 00 Pump Tank Size Nitrification Field: Total Square Feet Depth of Stone Bed Size Trench Width Total Length of All Trenches Number of Trenches Trench Length/ / Feet on Center Maximum Trench Depth Distance of Nearest Well 100' *DO NOT INSTALL SEPTIC WHEN WET* *WELL RECORD REQUIRED AT COMPLETION* ##k###kt#t#rt#t#trtttit#k#k#k#########tttt###t#t;tkR##k#rt####rt#tit##tki###fi##rtrtrt##rtrt##;tilt##k#tt##t##i##itR#ktik##rt#tt####kR TopoLL 10 %Slope Texture A - Structure 16I< Clay Min. Soil Wetness .` ••. v fo Soil Depth C I 1 P fop` , ,nR� Restric. Hoz. at £ �5 -t-la M 6 -3MQ. Pool Available space`y�ra�r,1no a' C o O"2 I Overall Class S OU P Gr * q Comments: - 6> a 5 M J I I iv 11 J I 9 y B R H o.v,a.. Fso' k Sol rv-PS'� s 3 o Filter Required Riser required when tank is more than 6 , inches deep. **NO GUARANTEE OR WARRANTY IS IMPLIN.QR GIVEN AS TO THE PERFORMANCE OR LENGTH OF TIME THIS SYSTEM WILL FUNCTION** ttirttt#3tk##t#iii##krtt#tt#trtrttttRRt#t*♦t##fiti#kittkt##kkik##rt#tiiiik####trtttt#trtrtki#t####t###R#ttttk#trt#t3Ri RR#rtf RRtR#k# *Improvement Permit has no expiration date and is transferable, but may be revoked if site plans or intended use changes for the proposed facility. An Authorization to Construct is valid for (5) rive years from date issued and is not transferable. Well Permit valid for 5 years provided site conditions do not change. Well location, installation, and protection must meet state and local regulations, and must be inspected and approved by a representative of the Catawba County Health Department before any portion of the installation is put into use. The siting of the well by the Health Department staff is to provide protection from known possible sources of contamination. No volume of water is guaranteed pt anp sit by the Health Department. Permit Date `�{' ID'{ I I C - , O EHS Owner/Agent-3-A-ov `," , ."� Septic Tans installed TB Date118'109 EHS Well Installed By Well Grout Approval Date Well Head Approval Date Date Sample Collected Date of Results Results EHS White - Office Yellow - Owner/Agent Pink - Building Inspection Authorization to Construct DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES Sheet —oj�, DIVISION OF ENVIRONMENTAL HEALTH n . , Q m + -�- PROPERTY ID 4- ON-SITE WASTEWATER SECTION r 1 COUNTY SOIL/SITE EVALUATION l lls a4aS _ 009j -7o 1nr T574T_.GTT-F WA ,TVW A TTi P r VdZ'VVAA l.LI ' r, J s,� t S6k st,sP,StxP Fri 3 i 4 DESCRIPTION Available Space ( 1945) System Type(s) Site LTAR OMMENTS INITIAL SYSTEM I REPAIR SYSTEM 3 I I OTH17R FACTORS ( 194(): j SITE CLASSIFICATION ( 1948): Ft 1 EVALUATED BY 5 f3o f� OTHER(S)PRESENT CATAWBA,COUkTy n I : Public Health Department Case # WLS2007 01550 Environmental Heah4Divisiyn Subdivision ROLLING GREEN d PO Box 389. 100-t, snuthW st Blvd; Newton, NC 2S65S Sect/BL/Ph/Lot # PT 6 \vs i (828) 465-8270 FAX (823) 465-8276 TDD (828) 465-8200 ! PIN# J � 372013242766 Applicant/Owner: DUSTIN OTTERBERG 7/8)9 /aa Site Address: 1129 ROLLING GREEN DR NEWTON NC Property Size: SF 4.21 ACRES Directions: FROM STARTOWN RD/ LFT ON SANDY FORD RD/ RT ON ROLLING GREEN DR/ AT END OF CUL-DE-SAC/ ROLLING GREEN SUBDIV/ LOT # 6 "Revised to show pool & garage`" Catawba County Health Department Operation Permit r'Lr,LL'L1 Ib IN QIP �- a. Q rw Svstem Code System Type: 1 j Description: 0�%o f ����{ r��'��' �7 Types V and VI systems expire in 5 years. (In accordance with Table Iva) Owner must contact health department 6 months prior to exiration for permit renewal. PERMIT CONDITIONS: 1. Performance: System shall perform in accordance with Rule .1961. II. Monitoring: As required by Rule. 1961. III. Maintenance: As required by Rule . 1961. Other: Subsurface system operator required? Yes No If yes, see attached sheet for additional operation conditions, maintenance and reporting. IV. Operation: This system has been installed in compliance with applicable North Carolina General Statutes, Rules for Sewage Treatment and Disposal, and All conditions of the Improvement Permit and Construction Authorization. i�ec r 7logIaF System Installer Installation Date g 1 `7 4 TAuhorized Agent Date of Operation Permit Issurance Form F OT,don k\Fourr.iVWLSAnn.rnr r n ! AWBA COUN'I,'l. r,mliFtcalth Department Case # WLS2007 01550 c rl = Subdivision Environmental Flealt' Division ROLLING GREEN PO Box 389, 100-1,�'butliwest Blvd. Newton. NC 28658 Sect/BL/Ph/Lot # PT 6 (828) 465-8270 FAX (828) 465-8276 TDD (828) 465-8200 PIN# 372013242766 Applicant/Owner DUSTIN OTTERBERG os,4ed SG Site Address: 1129 ROLLING GREEN DR NEWTON NC Property Size: SF 4.21 ACRES Directions: FROM STARTOWN RD/ LFT ON SANDY FORD RD/ RT ON ROLLING GREEN DR/ AT END OF CUL-DE-SAC/ ROLLING GREEN SUBDIV/ LOT # 6 "Revised to show pool & garage*" Improvement Permit Permit Valid For: Five years V/No Expiration Facility (Residential): House HOLISC X Mobile Home Multi-Fam Bedrooms _� New? Addition? Projected Daily Flow 4,6o g.p.d Water Supply Private Well? � Public? Semi -Public? Basement: Y Basement Plumbing: Y H_ otTub/Spa: Y Special Fixtures (explain): Proposed Wastewater System: �-5 -7o 12, Type: 11_L yp n Proposed Repair: 4^S -5 c. t2(!_)• Q M p Permit Conditions: Owner or Legal Representative SigJa re, ) Date: Authorized State Agent: i4 I Date: % / 0 /oc The issuance of this permit by the Healthment dor"not guarantee the issuance of other permits. It is the responsibility of the applicandproperty owner to insure that all Catawba County Planning/Zoning and Building Inspections requirements are met. This Improvement Permit is subject to revocation if the site plan, plat or the intended use changes, or if site conditions are altered. The Improvement Permit is not affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina 'Leis and Rides %or Sewage Treatment and Disposal Sv.ctems' (15A NCAC ISA .1900). Neither Catawba County nor the Environmental Health Specialist warrants that the septic tank system will continue to function satisfactorily for any given period of time. Authorization to Construct Wastewater Svstem (Required for Buildinq Permit) * See site plan and additional attachments ( ✓ ). Propose Wastewater System: a S� ` �' z� L t} t � ,� Type: j�T Wastewater Flow 4?0 g.p.d New Repair Ex ansion Soil LTAR: j 3 g,p,d,/ft2 Type of Facility: U 1-�..,a.. Basement: Y Basement Plumbing: y HotTub/Spa: Y Special Fixtures (explain): Wastewater Svstem Requirements Tank Size: Septic Tank 1 i0O 1101-117 gal Pump Tank gal Grease Trap gal 1) Drainfield: Total Area: i 1- OQ sq ft Total Length: y UD ft ft Maximum Trench Depth �- in Trench Width '3 c It Minimum Soil Cov 1 t in Minimum Trench Seperation It Distribution: Distribution Box Serial DistributionPressure Manifold LPP Other Additional Specificattion: � %a,. � � 1 � ra..r� s v�� �� �� , � nv i, 4a' L+ fit . -� J�14 A4 c re -t-;1( r! -.o Inc.) 'k I,Aj{'c 1' T. c..Lr sydA Authorized State Agent: 'J`" Permit Expiration Date: 0 12/11/2012 / /rave read and accept the specifications and all cone/ ions of thi -i ti s indicated. Owner or Legal Representative Signature:` r:\T,,l A\Fnrnr. VaILStvi rot Date: 7/1 7/o6 Date: Form B .i CATAWBA COUNTY F" �; , Public Health Ckpartment Case # WLS2007 01550 y Environmental Hcal�l Division Subdivision ROLLING GREEN PO Box 389, 100'A'Southwest Blvd, Newton, NC 28658 Seet/BL/Ph/Lot # PT 6 (828) 465-8270 FAX (8 28) 465-8276 TDD (828) 465-8200 PIN# 372013242766 Applicant/Owner: DUSTIN OTTERBERG Site Address: 1129 ROLLING GREEN DR NEWTON NC Property size: SF 4.21 ACRES Directions: FROM STARTOWN RD/ LFT ON SANDY FORD RD/ RT ON ROLLING GREEN DR/ AT END OF CUL-DE-SAC/ ROLLING GREEN SUBDIV/ LOT # 6 **Revised to show pool & garage** Proposed Use: Private SETBACKS: ✓ Public WELL PERMIT Semi -Public Other GROUTING DEPTH: MINIMUM 20 FEET 1. BUILDNG FOUNDATIONS 25 FT. 5. UNDERGROUND STORAGE TANKS 100 FT. 2 EXISTING & PROPOSED SEPTIC SYSTEMS -MIN. 50 FT. 6. STREAMS/BROOKS/CREEKS 50 FT. 3. EXISTING & PROPOSED SEPTIC REPAIR AREA - MIN. 50 FT. 7. LAKES/PONDS RESERVOIRS 50 FT. 4. SEWAGE PUMP SUPPLY LINE 50 FT. ALL OTHER POSSIBLE SOURCES OF GROUND WATER CONTAMINATION 100 FT. The well driller must verify all sepearations are adhered to before drilling the well. If the well driller is unable to maintain any of the above separations, contact the Health Department at (828) 465-8270 before drilling the well. SEE SITE PLAN FOR PERMITTED WELL LOCATION CueBy: � I` Customer Signature: I Lhi/o-7 Permit Issuance Date: (2Z ()Ilp WELL INSPECTION: / GROUTED DEPTH: 20' w DATE: 1 7't l bk INITIALS: IX 6 APPROVED CASING: PVC STEEL/ DATE: 1 INITIALS: CASING HEIGHT 12" ABOVE LAND S, RFACE �/ DATE: N' INITIALS: WELL COMPLETION REPORT REC7VED DATE: INITIALS: WELL HEAD APPROVED DATE: '1 11,3°1 / cz INITIALS: J 6 Y jO Well Driller Date Drilled Well permits are valid for 5 years from the date of issuance and are subject to suspension and/or revocation fro non-compliance with appropriate state and local rules and regulations, or if false information was given in order to obtain a permit. Wells shall be constructed in accordance with all state and local regulations and rules. The Well Completion Report must be submitted to the Health Department within 30 days upon completion of a well. `n) Au rized State Agent , ATdenv A\ForursVIVI-SAnn. n ?1a-ilog Final Approval Date Form D !jrF 1W -BA COUN'I;Y - Case # WLS2007-01550 Ndblit Flcalth Department Environmental Health Division Subdivision ROLLING GREEN PO Box 389, 100- 1 Southwest Blvd; Newton. NC 2865H Sect/BL/Ph/Lot # PT 6 (828) 465-8270 FAX (828) 465-8276 TDD (828) 465-8200 PIN# 372013242766 Applicant/Owner DUSTIN OTTERBERG Site Address: 1129 ROLLING GREEN DR NEWTON NC Property Size: SF 4.21 ACRES Directions: FROM STARTOWN RD/ LFT ON SANDY FORD RD/ RT ON ROLLING GREEN DR/ AT END OF CUL-DE-SAC/ ROLLING GREEN SUBDIV/ LOT # 6 "Revised to show pool & garage`" ® Improvement Permit er f 1tr=a0 Y Scale © Authorization To Construct [D Well Permit SITE PLAN +per, i- pQ-v:so-,a i-. y r_{ c", s+ o i1^ _, • p i..) � r 102- r ..� I V r e,.j � � � � �� r � �'" � !�t e. �C� 1� � .�Q..-F_�!^v �7� rc�rc., pe.r e...�.,e.rre{�•�.-� r� r7 J I �' t,C u +`! ;n,a„ n e:7 � t C? P✓ �' c. l l ti .� 1-a ;• '(, j sq\\^ �. y a •_ J , N System components represent approximate contours only. The cor installation to ensure that proper grade is maintained. Do not install revocation if the site plan or site conditions are altered. Aut o ized Stats Agent r:\TidASF, ,, 1VLSAun.-i P st`flag the system prior to beginning the under wet conditions. This permit is subject of Date Form C I DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES Sheet of_ DIVISION OF ENVIRONMENTAL HEALTH rr* V a. M IL Ps—,r w% I PROPERTY ID #- I . ON-SITE WASTEWATER SECTION COUNTY SOEL/SITEEVA)LUATION UJL5Q0oS_00q70 for ON-SITE WASTEWATER SYSTEM OWNER. () it; r6kr) . APPLICATI ON DATE a3 i ds i 'DESCRIVnON Available Space ( 1945) System Type(s) Sitc,LTAR COMMENTS. INITIAL SYSTEM T7- REPAM SYSTEM OTHER FACTORS( 1946): u A joc! SITE CLASSIFICATION (1948). Af PS EVALUATED BY - -:57 15 6 \.j OTHER(S) PRESENT 3