Loading...
HomeMy WebLinkAboutRBPR-07-2015-21889.TIFOwner THIS IS NOT A PERMIT Case # RBPR-07-2015-21889 CATAWBA COUNTY HEALTH DEPARTMENT PLAN REVIEW APPLICATION FOR ENVIRONMENTAL SERVICES Residential Building Pla Manufa turE1- ome <1-z— CE_ ` 1 IMPROVEMENT(R PLAWEL (-ABANDONMENT) 411( n MARK TRAVIS, 2898 ALEXIS RENEE CT, NEWTON NC 28658 13:7047350411 08285146560 OTHER:NA NAME TO APPEAR ON PERMIT Mark Travis SITE ADDRESS: 2264 SIGMON DAIRY RD, NEWTON NC 28658 NAME of SUBDIVISION: Lot N PROPERTY SIZE: Square Feet Acres 0.88 DIRECTIONS: Start off Hwy 10 about 2 miles on left beside Pioneer Or PRIMARY CONTACT: Owner SEWER TYPE: GALLONS PER DAY: 240 WATER SUPPLY: DESCRIBE WORK: Revised 3/10/16 - Applied for Replacement well & Abandonment. 24 x 36 1 Bedroom Doublewide 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? APPLICATION FOR: STRUCTURE TYPE: FACILITY TYPE: Mobile Home DESCRIPTION OF EXISTING STRUCTURES ON SITE (IF ANY) DIM EXISTING STRUCTURE: NUMBER OF EXISTING BEDROOMS: 1 New Structure : 7 11'iIT:��.I OTHER DESCRIPTION: PIN # 363918205406 Section/Block Septic Tank Private Well # OF OCCUPANTS: 1 PROPOSED CONSTRUCTION NEW STRUCTURE DIM:: 24 x 36 Desired system types (Improvement Permit or Authorization to Construct) ACCEPTED: ALTERNATIVE: CONVENTIONAL. OTHER: INNOVATIVE: ANY: YES Other described: APPLICATION FOR WELL CONSTRUCTION PROPOSED WELL TYPE: Individual Well REPLACE WELL?: YES APPLICATION FOR WELL ABANDONMENT ABANDONMENT TYPE: Bored 1--9 - ehapphcanon 03/10/2016 11 30 Page 1 of 8 g CATA\VBA COUNTY Case d RBPR-07-2015-21889 Public health Department Subdivision ti ... Environmental Health Division PIN# 363915205406 PO Box 389. 100-A Southwest Blvd, Newton. NC 28658 NAME ON PERMIT: ( MARK TRAVIS), 2898 ALEXIS RENEE CT, NEWTON NC 28658 ( Mark Travis) Site Address: 2264 SIGMON DAIRY RD, NEWTON NC 28658 Property Size: Square Feet Acres 088 Directions: Start off Hwy 10 about 2 miles on left beside Pioneer Dr 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 lines and corners and making the site access�ibl% sot a complete site valuation can be performed Date: Signature of Applicant or Agent An Environmental Health Specialist will contact you within 5 working days of application date. If you need further information or assistance please call 828-466-7291 AREA1 FEENAME': )_ ' ,,i ' DATE.. FEEAMOUNT; " t..: I.� .ems Y Improvement Permit Fee 07/07/2015 $150.00 Well Abandonment Fee 03/10/2016 $100.00 Well Permit & Inspection Fee 03/10/2016 $300.00 �`.. 0y.:TOTALFEES': r ... •wrP:,..,.:.. :=:.fj .5550.00 " 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 - chapphuawn 03/10/2016 11 30 Page 2 of 8 PAYOR Travis, Mark PAYMENTS CATAWBA COUNTY 100A SOUTHWEST BLVD NEWTON, NORTH CAROLINA 28658 PHONE: 828.465.8399 www. catawbacountync.gov TRANSACTION NUMBER: TRC -634900-10-03-2016 PAYMENT DATE: 03/10/2016 PAYMENT TYPE: Credit Card RECEIPT Thursday, March 10, 2016 INVOICE NUMBER FEE NAME FEE AMOUNT 03-16-326028 Well Abandonment Fee $100.00 TOTAL PAYMENTS: RBPR-07-2015-21889 CASE TYPE: Residential Building Plan Review WORK CLASS. SITE ADDRESS: 2264 SIGMON DAIRY RD, NEWTON NC 28658 Owner MARK TRAVIS, 2898 ALEXIS RENEE CT, NEWTON NC 28658 B 7047350411C:8285146560 ** NO PEOPLESOFT ACCOUNT ASSIGNED ** $400.00 Manufactured Home receipt 03/10/2016 11 30 Page I of I CATA BA THIS IS NOT A PER 41T COUNTY lv a.� CATAWBA COUNTY HEALTH DEPARTMENT Application for Environmental Services Page 1 Improvement Permit ❑ Authorization to Construct ❑ Septic Repair ❑ Septic Malfunction ❑ Septic Expansion V New Well Permit-❑/ Replacement Well ❑ Well Abandonmentt� Well Repair ❑ Existing System Inspection (Pre -Approval Required) ❑ Application is for Ne}w�Construccjtio E:1 Existing Facility S Property Address ZZ G `/ c n nn h, r_ /�, ✓ : /� ) Subdivision _11/PiN4r71i1 _/ 1V (_ -' ;�'16; Lot# Acres _ Section/Bloc base Driving Directions to Property i l« S' i7 A < , . h s ori O e , _. /iii? o n i L.e-k'-P NAME TO APPEAR ON PERMIT?1,Z Owner ❑ Applicant ❑ Contractor Applicant Contact Information Name Address Phone Phone 7V c/ 3 -2 Owner Contact Information Name Address Phone Contractor Contact Information Name Address Phone Ale- w�vJgi A/ c— 7_Zt-, i -l_ Cell Phone Cell Phone License # Cell Phone WHO WILL BE THE PRIMARY CONTACT? -,Owner ❑ Applicant ❑ Contractor Description of Existing Structures on Site / # of Bedrooms * I / Structure Dimensions Z q);a-%U # of Occupants Basement ❑ Yes No Basement Fixtures ❑ Yes,_O-No 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 „0No Does the site contain any jurisdictional wetlands? 1EI Yes ❑ No Does the site contain any existing wastewater s) stems? ❑ Yes _2-fJo Is any wastewater going to be generated on the site other than domestic sewage? ❑ Yes PNo Is the site subject to approval by any other public agency? ❑ Yes ❑ No Are there any easements or right of ways on this property? Describe Existing water supply, in use v0' Individual Well ❑ Community Well ❑ Semi -Public Well ❑ County/City/Township Water Line Is a public water supply available? ** ❑ Yes -ONO 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 ❑ Conventional 0 Innovative ❑ Other 0 Any CATAWBA THIS IS NOT A PERMIT CooNry wa CATAWBA COUNTY HEALTH DEPARTMENT -. Application for Environmental Services Page 2 Pro used Facility Type CJ Primary Residence New Re idence [:]Af dition to Reside ice # of New Bedrooms * j Project Description I,f�,'1 v 4 ✓ P Structure Dimensions .7—Y* U/) # of Occupants / Basement ❑ Yes _❑'Nto Basement Fixtures ❑ Yesi,�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 *t ❑ Food Service Specify Type #Bedrooms per Unit* j Structure Dimensions # Seats Floor Space -Entire Food Service Facility (Sq Ft) # Employees per Shift # of Shifts Dining Area (Sq. Ft.) ❑ Business Specific Type of Business Retail Floor Space # of Employees per Shift # of Shifts ❑ Other Facility Type Specify 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 a—Bored ❑ Dug ❑ Unknown Well Repair Requested ❑ Yes ❑ No Describe Calculated Design Flow, Commercial f 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 roonis 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. I 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 RE TRIP 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 atm solely responsible for the proper identification and labeling of all property lines and comers and making the site accessible so that a complete site evaluation can be performed. Signature of Owner or Agent�d°��/ t Date Printed Name of Owner or Agent Catawba County Environmental Health Parcel: 363918205406, 2264 SIGMON DAIRY 1in=50ft RD 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 arses or may arise from this map/report product or the use thereof by any person or entity Copyright 2014 Catawba County INC 03/10/2016 Owner THIS IS NOT A PERMIT Case # RBPR-07-2015-21889 CATAWBA COUNTY HEALTH DEPARTMENT PLAN REVIEW APPLICATION FOR ENVIRONMENTAL SERVICES Residential Building Plan Review - Manufactured Home IMPROVEMENT MARK TRAVIS, 2898 ALEXIS RENEE CT, NEWTON NC 28658 13:7047350411 0.8285146560 OTHER:NA NAME TO APPEAR ON PERMIT Mark Travis SITE ADDRESS: 2264 SIGNION DAIRY RD, NEWTON NC 28658 NAME of SUBDIVISION: PROPERTY SIZE: Square Feet Acres 088 DIRECTIONS: Start off Hwy 10 about 2 miles on left beside Pioneer Dr PRIMARY CONTACT: Owner GALLONS PER DAY: 240 PIN # 363918205406 Lot# Section/Block SEWERTYPE: Septic Tank WATER SUPPLY: Private Well DESCRIBE WORK: 24 x 36 1 Bedroom Doublewide 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? APPLICATION FOR: STRUCTURE TYPE: FACILITY TYPE: Mobile Home DESCRIPTION OF EXISTING STRUCTURES ON SITE (IF ANY) DIM EXISTING STRUCTURE: NUMBER OF EXISTING BEDROOMS: New Structure PRIMARY RESIDENCE OTHER DESCRIPTION: # OF OCCUPANTS: 1 PROPOSED CONSTRUCTION NEW STRUCTURE DIM:: 24 x 36 Desired system types (Improvement Permit or Authorization to Construct). ACCEPTED. ALTERNATIVE, CONVENTIONAL. OTHER: INNOVATIVE: ANY YES Other described. 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 u erstand that I am solely responsible for the proper identification and labeling of all property lines and corners and making the site accessible so complete srte,evaluation can be performed. Date. T-7—Signature of Applicant or Agent An Environmental Health Specialist will contact you within 5 working days of application date. If you need further information or assistance please call 828-466-7291 AREA1 E9 - chappliwoon 07/07/2015 08 56 Page t of 4 `ABw CATAwBA COUNTY Case # RBPR-07-2015-21889 v �% 'Public Health Department Subdivision Environmental Health Division 363918205406 w . PO Boa 389, I00 -A Southwest Bkd, Newton. NC 28658 PIN# NAME ON PERMIT: (MRK TRAVIS), 2898 ALEXIS RENEE CT, NEWTON NC 28658 ( Mark Travis) Site Address: 2264 SIGMON DAIRY RD, NEWTON NC 28658 Property Size: Square Feet Acres 088 Directions: Start off Hwy 10 about 2 miles on left beside Pioneer Dr FEENAME DATE FEE AMOUNT Improvement Permit Fee 07/07/2015 $150.00 TOTAL FEES' $150.00 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 - ehapphcaoon 07/07/2015 08 56 Paee 2 of 4 `1 THIS IS NOT A PERMIT _u` uNT1 — — CATAWBA COUNTY HEALTH DEPARTMENT Application for Enviromnental Services Page 1 Improvement Permi� Authorization to Construct ❑ Septic Repair ❑ Septic Dlalfunction ❑ Septic Expansion ❑ New Nell Permit ❑ Replacement Well ❑ Well Abandonment ❑ Well Repair ❑ Existing System Inspection (Pre -Approval Required) ❑ Application is for New Conslructio ❑ Existing Facility ❑ Property Address �Z �5, S (on/ �a, / i �� Subdivision �� L✓-�, // L Z/�5 [S Lot# Acres : tubo L Section/Block/Phase Driving Directions toProperty S7/�� 4�-z � x/j /J cr nn 10- J ,��,. NAME TO APPEAR ON PERAHT`/U Owner ❑ Applicant ❑ Contractor Applicant Contact Information Name Address Phone Owner Contact Information Name /f c/ /_ T a r, - , Address Z9R A /, x )-s R _ ni c e. ' Phone dV 7 0 L/ 7 3 S(_) N// Contractor Contact Information Name Address Phone Cell Phone Cell Phone FZ I Cell Phone WHO WILL BE THE PRMIARY CONTACT?Owner ❑ Applicant ❑ Contractor Z y ��n�� JR_ i-/„ �n1 r4fc �t.i/ Description of Existing Struc es on Site�3� X ,,. se e # of Bedrooms * j St cure Dimensions 3 Cx 7- 1) # of Occupants Basement ❑ Yes 'o Basement Fixtures 0 Yes 5) No The Applicant shall notify the -lo, cal health department upon submittal of this application if any of Ihe following apply to the property in question. If the answer to any question is "yes", applicant must attach supporting documentation - in Yes &Nio Does the site contain any jurisdictional wetlands? _Xlyes )fro Does the site contain any existing wastewater systems? ® Yes E21No Is any wastewater going to be generated on the site other than domestic sewage? Yes JT;o Is the site subject to approval by any other public agency? ® Yes -0-NO Are there any easements or right of ways on this property? Describe _, . - - - - - - --n..._ ._ �.T ..., ... - - -- u ..,,. _ Existing water supply in use Individual 'Jell ❑Community Well EJ 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) ❑ Accepted ❑ Alternative 0 Conventional ❑ Innovative ❑ Other Any BA THIS IS NOT A PERMIT �`� �_` CATA`VBA COUNTY HEALTH DEPARTMENT Application for Enviromnental Services Page 2 Pro osed Facility Type Primary Residence ❑ N w Resid nce F -1A tion to Residence # of New Bedrooms * t Project Description '7,?u%/t_ ✓ i� Structure Dimensions Z<1x D C # of Occupants Basement ❑ Yes [� No Basement Fixtures ® Yes ® No ❑ Accessory Structure(s) Describe # of New Bedrooms *t if applicable Structure Dimensions # of Occupants Accessory Dwelling ❑ Yes ❑ No Plumbing ❑ Yes ❑ No Describe Plumbing Needed ❑ Multi -Family Residence # Units #Bedrooms per Unit* j Total # Bedrooms *t Structure Dimensions ❑ Food Service Specify Type # Seats Floor Space -Entire Food Service Facility (Sq Ft) # Employees per Shift # of Shifts Dining Area (Sq. Ft.) ❑ Business Specific Type of Business Retail Floor Space # of Employees per Shift # of Shifts ❑ Other Facility Type Specify 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-VUnlmown Well Repair Requested ❑ Yes ❑ No Describe Calculated Design Flow, Commercial j 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 ADDTTIONAL 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 lays and rules. I understand that I am solely responsible for the proper identification and labeling of all property lines and corners and malting the site accessible so that a complete site evaluation can be performed. Signature of Owner or Agent.. %% Date Printed Name of Owner or Agent /�///�r� /� L �/ // r.,u ��a i z Parcel Report Parcel Report- Catawba County NC Parcel Information: Parcel ID: 363918205406 Parcel Address: 2264 SIGMON DAIRY RD City: NEWTON, 28658 LRK(REID): 30472 Deed Book/Page: 2301/1068 Subdivision: Lots/Block: / Last Sale: Plat Book/Page: Legal: 2264 SIGMON DAIRY RD Calculated Acreage: .880 Tax Map: 047N 02004 Township: NEWTON State Road #: 2013 Tax[Value Information: Tax Rates(pdf) City Tax District: All in County County Fire District: NEWTON RURAL Building(s) Value: $0 Land Value: $12,400 Assessed Total Value: $12,400 Year Built/Remodeled: / Current Tax Bill Miscellaneous: Building Permits for this parcel. Building Details WaterShed: Voter Precinct: P34 Parcel Report Data Descriptions List all Owners Deed History Report Owner Information: Owner: TRAVIS MARK WILLIAM Owner2: Address: 2898 ALEXIS RENEE CT Address2: City: NEWTON State/Zip: NC 28658-8914 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: Zoning3: Zoning Overlay: DWMH-O Small Area: STARTOWN Split Zoning Districts: / Zoning Agency Phone Numbers Firm Panel Date: 2007-09-05 Firm Panel #: 3710363900J 2010 Census Block: 2003 2010 Census Tract: 011702 Agricultural District: Assessment Report Page I of 1 This map/report product was prepared from the Catawba County, NC Geospabal 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 entry -- -- --- "" ' - - © 2015, Catawba County Government, North Carolina. All rights reserved. -�- a Iso �jGI kin littp:Hgis.cataNvbacountyne.gov/nomap/parcel_report.php?key=363918205406&typ=P 7/7/2015 Catawba County Environmental Health Parcel: 363918205406, 2264 SIGMON DAIRY 1in=50ft RD 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 07/07/2015 CATAWBA-LINCOLN-ALEXANDER DISTRICT HEALTH DEPARTMENT HICKORY, N. C.—NEWTON, N. C—LINCOLNTON, N. C.—TAYLORSVILLE, N. C. Phoncs 016mond 53883 ft , I d-2011 REgem 5-5521 MElrosa 2-3101 PERMIT TO INSTALL SEPTIC TANK > ,^ PERMIT NO....: -.. ...� PERMIT DATfir. )... Owner ... . CGS-,... .�..-,st.: ...............Address.......J��l.... /.�(,4>✓�GC�"�-A-^,............. Tenant ..... .........................Address ... . . .... .. .. ....... ................ Installed by..... _,R t ...�. • Address ... . -..... - ... . ?, L �.................� .......- LocaLion of Property i%-V.�.. ..<,ll�l.�' �,. n....... .... ��^'.�-"+:�, ... LLCM-�:.�......... / r � .. t!!.'C-..... ........ 7 Kind of tank.. .. Size ........ ..... ....Length of trench.... ...Z�_ .. .. NOTIFY HEALTH DEPARTMENT AT LEAST EIIC/HT HOURS BEFORE TANK IS TO BE INSPECTED Final Inspection... .(moi .'.=-.�. [� { (/)Disapproved(� ) . ...........13.. -- -� Approved Remarks: .. ...... . .................. ... ..... .... ........... .... .. ........ .........�'rYr ..... .................... .. ...... First five feet of line from outlet'from house should be of cast iron soil pipe. Sanitarian. J i Sketch of tank and line showing dis- tance from dwelling and well on subject Q property and on adjoining property. grilJ� R �V' l ( 3 E� I k 1v� '' •F ' �'� ' � F WA • �t : f �•,} �,�- ,.,���: E ftp,. �'a#., +� `� y,�j`•yi;, i y 4' q-• � t f 'I jI ..•' °�' r to I T e d } '• � ••� +- j ,� , 1 I I - �°. a �. •'14. _ l ,. F �i +• � •: ; ''• � e'� T.i"�• ... I e E [A*.� 1. .v , 1 M1 , . A ..• i.� f-+ •. - 1 Til., - M v " ' ..., ° L ' .. _., •. .' a :.. ...,. •. f `,{,{ , f�..' e4 moi.. � F�,4��+�' �I�. tip...•+ d�'�k.,, �°. y` S. t ' 1 Il e VC 1, tLH I . . 2 .74 f5 SI i 1 lip I , LIM kt- `!0 7.a M1 int PhN f5 SI i 1 lip I , LIM kt- `!0 ` 1 'T • .. Y �a • � 'S it � i ,���� �r. .Sr,� •tet y. , y w �rPip Ir* �� F • a r ty'i � I r ry4; t y .•ti . aF f u i -.. • �r ��- xM� ,� � yiy �,1l�p•T�� s". i v � L F d } �I. yrs � � �, ..,.i4 �, F i• nr � r�4 yam' I'.r. •� •� 1T4Or dw no �Sa ` 1 'T • .. Y �a • � 'S it � i ,���� �r. .Sr,� •tet y. , y w �rPip Ir* �� F • a r ty'i � I r ry4; t y .•ti . aF f u i -.. • �r ��- xM� ,� � yiy �,1l�p•T�� s". i v � L F d } �I. yrs � � �, ..,.i4 �, F i• nr � r�4 yam' I'.r. •� PIP •kF rY I] t��ti 'yk+ •i2 �, �• i _ Y .., � ,.°•y � ,�I,i �rt� I ti '; a•� j. i.� �.-, ,t . ■ ,� f ''� 1 r"� 1� lit, • i'p . } 1 ■ - ..yle ti a+11F..-'.IES 1�•�L�'- ...I Jr•i ` i., y�, a.��yad•t_ � } J�' a } , F� I r ?.h y. � J �!����ti�.irl - ; �L � ■ , �rIF� 5L4,r FF �k. FTL `�j '•r4 I� ���11y 5� r� `'� � i. ' � `;ir 1~�•�F e� 1- J t " C f�� 1'y -L" • 111 �'F� 1` x4. r 3� .P 1v, ili .raj, + _ ✓ tom. .+Gtr 1 +Fr •'7. y cru i 1�' i . ' •'! T ' � I��S � � � fir. , r - � p{ �' it 4Te 4 5�.+ti"7 , i 3. r,' S . .� +pr y , •. .� .-1•- f frN t a r -�e �'' 16° ' � s,�. -P`° • � 1 �,� � L � - -r .fie. # a /a 5` � 'il a t L - ••.M �•.+. �i i • 6, 'I r l[T I � I 9 I A f G 5 � I � � } -�I -�k.1r 11 ` ° r��{� `i�rv, L- ''i :� ,_.�• Yt'• - :-°i_ { � k1 . \ -.! 9� •, .11r' it i's_ f+ I" ` i''. ®4i. ' 1j ��r ,- �L.. r� r•'x,•• m eL e f • r _, I , r 'j L JAL t rkt i I _ � dl • f`1 � ,• 5 � 44 �•L ~'moi 4`. L -* _ � ALI- A. Y � F A I . r 1 �..3•. , - 's � -. � r , L , , � I , £ice �, r' •'� a' '• -. ,,.. i 1 • ' ' 7 1 t � 'sit y 1 J� e r -.;,r � —' Y ,y - k•,k yr ELI % ' r , 1 . ti s� 1 � + , _��� ��''ry'. ,�° � r•ir 1 - ��'� _ Vii* ,; �� 1 �'' ; .Wi'''t a- y. , ° � frl ' ;' 1 -� -,: r � �1 ..5 , �. 1 y 'S . / f r� 1 •,. -tea ;�#F _ jam, h �%1' .1." ,. '�k i •�k� ` 1 .: -�1, k C� a - r r � - • k s 71 14 ±[ # t 01 r r r .. IL • r 1 , r ' ty e ■ {' �•.l ' 1' •l } i h1.: `� X71. } ,•'T,I tt r r•, 1 ,:' r r + Julia English From: Jason Boyd Sent: Friday, December 18, 2015 3:42 PM To: john.brooks@dhhs.nc.gov Cc: Mike Cash; Julia English; Jodi Stewart Subject: Mark Travis Well Varinace Request Plan Case 21889 John, I went by Mr. Travis' property earlier this morning and took measurements and several pictures that were forwarded to you by Julia to assist in Mr. Travis' variance request for his well. These pictures have been attached with the plan case for our records by Julia. The well is 12' 2" from the corner of his home that has not been approved by our building inspections department as of yet. It does not appear to have been grouted based on probing around the outside edge of the well tile. There are also no well tags indicating driller, depth, etc.. The well does not have a sanitary seal exiting from the top or any spigot from which to take samples. The well is located 4' 2" from some 4"x4" posts that have recently been put up on the property as well. Mr. Travis has been constructing a privacy fence on the other side of the home and I am speculating that this is what the posts have been put in place for based on where they are located and spacing in between posts. I have also been unable to locate the drain field for the septic system based on probing or verify the property boundaries for the lot on site. I spoke with Mr. Travis again by phone at 1: 35PM today and explained that he would need to have system uncovered and the property lines marked prior to any further evaluation for the septic system. I am unable to determine if the well meets the required 50' minimum setback requirement until the drain field is uncovered or otherwise located by a septic installer/inspector. Mr.Travis said that he would get with someone and get back with me on these issues to proceed with the application for the improvement permit. If there are any other questions or concerns, please feel free to contact me by e mail or phone at 828-244-0943. Jason Boyd REHS 1810 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 All water supply wells not considered"Private Drinking Water Wells"and including irrigation, industrial,and commercial wells. WELLS OTHER THAN WATER SUPPLY UNDER 15A NCAC 02C.0108 Including monitoring and recovery wells. Print clearly or type information. Illegible.cuhmittals will be returned as incomplete. DATE: e. I , 20 1 S PERMIT NO.: (to be completed by DWRJDPH) A. WELL OWNER— For single family residences list the property owner(s). For all others, list name of the business, organization,orr government� agency and person delegated signature authority: /114, K W �.►.�.%S Mailing Address: 6 .9F A/C,)C/S /\CA' City: __MC CP �+ State:ri /VC Zip Code:ZBfanf Couunnty: C4 1L 0. A 1 Day Tele No.: 10 Li 3 Z J 0 933 J Cell No.: O L? S /L7 EMAIL Address: /12/40 •-evii51 ) k04'vte�•! .c.OYIt Fax No.: B. PHYSICAL LOCATION OF WELL SITE �/ J� (1) Parcel Identification Number(PIN)of well site: 3(/p 3 q//8 ZQ� 06 County: C.+4 4s d (2) PhysicalAddress(if different than mailing address): 2 2 G -/ ,S f)yt/ to bt/ R "2- S City: �C°_u-�"L� /1/ State:NC Zip Code: C. WELL DRILLER INFORMATION(if known) Well Drilling Contractor's Name: d o 1U`t kw°£ " NC Well Drilling Contractor Certification No.:Company Name: Contact Person: City: State: Zip Code: County: Day Tele No.: Cell No.: _ EMAIL Address: Fax No.: Form GW-22V Page 1 Revised February 2013 D. 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 provides equal or better protic:;/- ction of thegroundwater. . re.4.5oAi "i 1v42- vae-1k G S • a.VS 4 °rt.- • L 1 2 f7 1v I5 Tall G1v lb aivto, , . r ti! ✓ t7 • (4 al /O.S d • 19%, , IIL I 10 /1.t7- C&V f '. A 0 D . tIV1, . ' tr U , ' r a vim. } 1 E. ATTACHMENTS—Provide the following information as attachments to this application: (1) 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. C. SIGNATURES d-pyl, /1/ ii�vu.,who ll , Signature of Person Respo sible for Well Construction(typicallyic the well driller) Print or Type Full Name of Person Responsible for Well Construction (typically the well driller) Signature of County Environmental Health Specialist Print or Type Full Name of County Environmental Health Specialist Per 15A NCAC 02C .0118 the Secretary of the Division of Water Resources or the Division of Public Health may require submittal of information deemed necessary to make a decision on the variance, may impose conditions as part of the decision, and shall respond in writing to the request within 30 days of receipt of the variance request. A variance applicant who is dissatisfied with the decision of the Director may commence a contested case by filing a petition as described in G.S. 150B-23 within 60 days after receipt ref the decision. Form GW-22V Page 2 Revised February 2013 ia [ .:• • V. 7 IT i 1 /J f 1b ' t' . ti ILrt t �•�, ` t . -oar • - .- • -,• . . c.. 4f*. ,,.1 A , ,_ 4 . . . , , ,,„,:•,,, .:•. , • • 4,,,i,e- ,a• _ 4.- 11. 0 r . ' 4,4t;"1: 'eftv i, \ 9 .'• 6"" to ! .4,' to 'IL ii 4111E44.0.4 • (Oil I; ' , am+. • *WV: .l.rw --$ - - ftti41 w ` �ine d • • 1; \ t4 x a 4 r O i =jk'ea iotio) \ , "50.5 Z V. , I 4,..! e \r. ` ��' • ssse O->��R 4I0 r % e r. . •ce kotO" i„ j • •e. vv _ A ; Alf if' :. 11:1" 411r , ..), ,,, 6 6 V 04. ' . •t . s. iA, , lic 401, 1> F ... IW% .614 ,,,,,,. , . . . sfri. . _... ,, :. ,p , . ., .• . .„,,Akiti,. AO. ir 4. .", . . 4- icrif. ,:'‘ ,Wit`..1)4t!i'* ': it 4„,.., ,,, ... ,• . , ..,.. 4,-. t. • ., ill" . . ,..., - is ,r • yCR��k ¢@SS t North Carolina Department of Health and Human Services Division of Public Health Pat McCrory Richard O. Brajer Governor Secretary Daniel Staley Division Director Onsite Water Protection Branch February 23, 2016 Mark Travis 2264 Sigmon Dairy Rd Newton,NC 28658 Re: Denial No. JMB727 Private Well Located Less than 25' from Building Perimeter [Rule 15A NCAC 2C .0107(a)(2)(M)] Property location: 2264 Sigmon Dairy Rd Newton,NC 28658 Dear Mr. Travis; On December 16, 2015 the On-site Water Protection Branch received your request for a variance from the Well Construction standards, Title 15A North Carolina Administrative Code Subchapter 2C .0100. The request for a variance concerns a water supply well on the referenced property that serves a single family dwelling. An addition is proposed for the home that would be within twenty-five feet of the well. Information provided by the Catawba County Health Department and property owner, indicates that the well does not have piping and wiring exiting twelve inches above ground and is not properly grouted. Rule 15A NCAC 2C.0118 provides for a variance if facts support a conclusion that the use of the proposed well "will not endanger human health and welfare or the groundwater" as stated 15A NCAC 2C.0118(a)(1). Because the well is not properly constructed, thus the facts do not support a conclusion that the well would not endanger human health and welfare or the groundwater. As a result,your request for a variance is denied. You have a right to a formal appeal of this decision. To pursue a formal appeal, you must file a petition for a contested case hearing with the Office of Administrative Hearings, 6714 Mail Service Center, Raleigh,N.C. 27699-6714. To get a copy of a petition form, you may write the Office of Administrative Hearings, call the office at(919) 431-3000, or download the petition from the OAH web site at www.ncdhhs.gov • www.publichealth.nc.gov Tel 919-707-5874•Fax 919-845-3973 LI- Location: 5605 Six Forks Road• Raleigh,NC 27609 NCI"C� q/�l'� Mailing Address: 1642 Mail Service Center•Raleigh,NC 27699-1931 ;� ��{� An Equal Opportunity/Affirmative Action Employer PP„ Health Travis February 23, 2016 http://www.ncoah.com/forms.html. The petition for a contested case hearing must be filed in accordance with the provision of North Carolina General Statutes 130A-24 and 150B-23 and all other applicable provisions of Chapter 150B. N.C. General Statute 130A-335 (g) provides that your hearing would be held in the county where your property is located. Please note: If you wish to pursue a formal appeal, you must file the petition form with the Office of Administrative Hearings WITHIN 30 DAYS OF THE DATE OF THIS LETTER The date of this letter is November 13, 2015. Meeting the 30-day deadline is critical to your right to a formal appeal. Beginning a formal appeal within 30 days will not interfere with any informal review that you might request. Do not wait for the outcome of any informal review if you wish to file a formal appeal. If you file a petition for a contested case hearing with the Office of Administrative Hearings, you are required by law(N.C. General Statute 150B-23)to serve a copy of your petition on the Office of General Counsel,N.C. Department of Health and Human Services, 2001 Mail Service Center, Raleigh, N.C. 27699-2001. Do not serve the petition on your local health department. Sending a copy of your petition to the local health department will not satisfy the legal requirement in N.C. General Statute 150B-23 that you send a copy to the Office of General Counsel, N. C. Department of Health and Human Services. If you have any questions regarding this variance, please contact me at (828) 713-3335. Sincerely, John M. Brooks R.E.H.S, MS