Loading...
HomeMy WebLinkAboutRBPR-03-2016-23297.TIF SBA �G THIS IS NOT A PERMIT Case # RBPR-03-2016-23297 Ae2 a CATAWBA COUNTY HEALTH DEPARTMENT 0 In• -4 ,o, PLAN REVIEW APPLICATION FOR ENVIRONMENTAL SERVICES 1842 sM Residential Building Plan Review - Building New n. •o U 1 T � AUTH CONST- NEW WELL 1:14- 41 ". t . -y Owner JIMMY L. & SHIRLEY C. MOORE, 36 SULLIVAN POINT LN, TAYLORSVILLE NC 28681 C:8282173441 NAME TO APPEAR ON PERMIT Jimmy L. & Shirley C. Moore SITE ADDRESS: 4288 JA YOUNT FARM RD, CONOVER NC 28613 PIN # 374309150460 NAME of SUBDIVISION: Lot# \ Section/Block PROPERTY SIZE: Square Feet Gs3.51 J DIR ECTIONS: County Home Rd to JAY PRIMARY CONTACT: Owner SEWER TYPE: Septic Tank GALLONS PER DAY: 600 WATER SUPPLY: Private Well DESCRIBE WORK: New 5 bedroom home 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? No 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: New Structure STRUCTURE TYPE: PRIMARY RESIDENCE FACILITY TYPE: Single Family Residence OTHER DESCRIPTION: DESCRIPTION OF None EXISTING STRUCTURES ON SITE (IF ANY) DIM EXISTING STRUCTURE: NUMBER OF EXISTING BEDROOMS: #OF OCCUPANTS: 2 PROPOSED CONSTRUCTION NEW STRUCTURE DIM:: 8516"x 62'8" #OF NEW BEDROOMS:: 5 BASEMENT? No BASEMENT FIXTURES? No PLUMBING REQUIRED?Yes 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?: NO E9-cl application 03/01/2016 16:40 Page 1 of 4 e CATAWBA COUNTY Case rt RBPR-03-2016-23297 s1� Public Health Department Subdivision 2 ;�'-'� K Environmental Health Division PIN# 374309150460 "I§- PO Box 389. 100-A Southwest Blvd,Newton.NC 28658 1gs2 su NAME ON PERMIT: (JIMMY L. & SHIRLEY C. MOORE),36 SULLIVAN POINT LN, TAYLORSVILLE NC 28681 ( Jimmy L. & Shirley C. Moore) Site Address: 4288 JA YOUNT FARM RD, CONOVER NC 28613 Property Size: Square Feet Acres 3.516 Directions: County Home Rd to JA Yount 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 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 accessible so that a complete site evaluation 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 AREA2 13x4 s `#r'P x a tiq c t i d i v F€�i l 1 J I E I 'Il ri a fitiP l�E 'f E _ i S 6. w s'�� t_.iFiEENAMEkil-f i'ar F:,. :r u.E!eig v a' .itn,,,,s DATE ,,s,, ,FFEE'A'IViOUNT,na Authorization to Construct Fee (New/Expansion) 03/01/2016 $300.00 Fee Well Permit& Inspection Fee 03/01/2016 $300.00 yam„ TOTAL FEES r"'n tt f saa . 4° r $ $600 00 t1" S .� e r ur+ �r it •ts,lm e'4461144St 0.atrial ,:r . .. . g 5 u- :i ., a_4' .7, ,-0: 3u :" r ha,? ,tr 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-ehapplication 03/01/2016 16:40 Page 2 of4 Lt 2 THIS IS NOT A PERMIT Case # RBPR-03-2016-23297 /EY ��. CATAWBA COUNTY HEALTH DEPARTMENT D • ` o ro PLAN REVIEW APPLICATION FOR ENVIRONMENTAL SERVICES 5;1.11 ti 842 5M Residential Building Plan Review - Building New o r \ o o h .. r r •AUTH CONST - NEW WELL 0"j• Owner JIMMY L. & SFIIRLEY C. MOORE, 36 SULLIVAN POINT LN, TAYLORSVILLE NC 28681 C:8282173441 NAME TO APPEAR ON PERMIT • • Jimmy L. & Shirley C. Moore SITE ADDRESS: 4288 JA YOUNT FARM RD, CONOVER NC 28613 PIN # 374309150460 NAME of SUBDIVISION: SPRING HILL Lot# 3 PTS 11 2 SectionBlock F PROPERTY SIZE: Square Feet Acres 0.35 DIRECTIONS: County Home Rd to JA Yount Rd PRIMARY CONTACT: Owner SEWER TYPE: Septic Tank GALLONS PER DAY: 600 WATER SUPPLY: Private Well DESCRIBE WORK: New 5 bedroom home 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? No 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: New Structure STRUCTURE TYPE: PRIMARY RESIDENCE FACILITY TYPE: Single Family Residence OTHER DESCRIPTION: DESCRIPTION OF None EXISTING STRUCTURES ON SITE (IF ANY) DIM EXISTING STRUCTURE: NUMBER OF EXISTING BEDROOMS: #OF OCCUPANTS: 2 PROPOSED CONSTRUCTION NEW STRUCTURE DIM:: 856"x 62'8" #OF NEW BEDROOMS:: 5 BASEMENT? No BASEMENT FIXTURES? No PLUMBING REQUIRED?Yes 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?: NO E9-ehapplication 03/01/2016 15:15 Page I of 4 4$A CATaWBA COUNTY case# RBPR-03-2016-23297 ti 2 Public Health Department Subdivision SPRING HILL < `I Environmental Health Division 4 PO Box 389. 100-A Southwest 131vd.Newton.NC 28658 PIN# 374309150460 /8.2 m NAME ON PERMIT: (JIMMY L. & SHIRLEY C. MOORE), 36 SULLIVAN POINT LN, TAYLORSVILLE NC 28681 ( Jimmy L. & Shirley C. Moon Site Address: 4288 JA YOUNT FARM RD, CONOVER NC 28613 Property Size: Square Feet Acres 0.35 Directions: County Home Rd to JA Yount 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. 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 acce ble so that a comp) site evaluation can be performed. Date: I//0/),16 Signature of Applicant or Agent /A0-no )27e7rS529 An Environmental Health Specialist will contact you wi n 5 workinr •:ys of application date. If you need further information or assistance please call 828-466-7291 AREA2 ############################################################################################################ FEENAME DATE FEE AMOUNT Authorization to Construct Fee (New/Expansion) 03/01/2016 $300.00 Fee Well Permit & Inspection Fee 03/01/2016 $300.00 TOTAL FEES S600.00 FEES ARE NON-REFUNDABLE ONCE A SITE VISIT IS MADE OR WORK ONA PLAN REVIEW HAS COMMENCED SYSTEM REDESIGN AND/OR RETRIP WILL INCUR AN ADDITIONAL CHARGE (SEE FEE SCHEDULE) • E9-ehapplication 03/01/2016 15:15 Page 2 of 4 CATAWBA THIS IS NOT A PERMIT COUNTY CATAWBA COUNTY HEALTH DEPARTMENT '=- :. *.�� �. Application for Environmental Services Page 1 Improvement Permit ❑ Authorization to Construct Septic Repair H Septic Malfunction ❑ Septic Expansion H New Well Permit>llReplacement Well 7 Well Abandonment n Well Repair ❑ Existing System Inspection (Pre-Approval Required) H Application iss/for New Construction H Existing Facility ❑ Property Address f� 'GG ° tt�/tama�Subdivisio v%%%% Lot# i Acres -1,`*.)l(19 2 , y��� y�ectionBlock/Phase Driving Directions to Property j Y4-9 / ��0�1-, NAME TO APPEAR ON PERMIT? lYl Owner ❑ Applicant ❑ Contractor Applicant Contact Information TC Name Address Phone Cell Phone i Owner C I ntact Informaton j\-- Name DZIT ii Addr:: 5 6 . // 7i.az "ter/43-7.10.-44.44 7j'� as Phone.9-,;) I y9_5-57? Cell Phone V g'; /17 3/E / Contractor Contact Information Name License# Address Phone Cell Phone WHO WILL BE THE PRIMARY CONTACT?t Owner ❑ Applicant H Contractor Description of Existing Structures on Site (�f�f # of Bedrooms *t Structure Dimensions # of Occupants�I \�`1 J Basement ❑ Yes n No Basement Fixtures n Yes El VI .-- 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 g No Does the site contain any jurisdictional wetlands? ❑ Yes all No Does the site contain any existing wastewater systems? ❑ Yes n No Is any wastewater going to be generated on the site other than domestic sewage? ® Yes ❑ No Is the site subject to approval by any other public agency? fF Yes ❑ No Are there any easements or right of ways on this property? Describe he 5-141-(ICC — Existing water supply in use [✓Individual Well ❑ Community Well ❑ Semi-Public Well ❑ County/City/Township Water Line Is a public water supply available? ** n Yes E--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 ❑ Conventional ❑ Innovative ❑ Other g"-Any • CATAWBA THIS IS NOT A PERMIT COUNTY CATAWBA COUNTY HEALTH DEPARTMENT Noah n�a Application for Environmental Services Page 2 Gro� Proposed Facility Type ❑ Primary Residence [1 Nettce ❑ Addition to Residence #of New Bedrooms *1' Project Description Structure Dimensions 6./42( 6;2-7 #of Occupants �- Basement ❑ Yes U] No Basement Fixtures n Yes No ❑ Accessory Structure(s) Describe # of New Bedrooms *j' if applicable Structure Dimensions #of Occupants Accessory Dwelling ❑ Yes n No Plumbing n Yes ❑ No Describe Plumbing Needed ❑ Multi-Family Residence# Units #Bedrooms per Unit*j Total # Bedrooms *t Structure Dimensions n Food Service Specify Type # Seats Floor Space-Entire Food Service Facility (Sq Ft) # Employees per Shift # of Shifts Dining Area(Sq. Ft.) n Business Specific Type of Business Retail Floor Space # of Employees per Shift # of Shifts Other Facility Type Specify If Church # of Seats _ Kitchen C Yes n No If Daycare Specify Occupancy Application for Well Construction/Abandonment/Repair Proposed Well Type n✓'individual Well n Semi-Public Well H Community Well Abandonment Type n Drilled n 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 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. 7 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 lines and corners and making the site accessible so that a complete site evaluation can be performed. • Signature of Owner or Agent d- 227 - Date /4 / b Printed Name of Owner or Agent f/ ivy L: m dv,kF O O O 62.8' m 0 r < Q off o (-) W z 187' co m cn m 0 0 -n -„ 0 T o 1\k" s iit 3 m,o 4 ^' r 14 r te` 170' 39.8, T2-2 0 m m a r CO C p o CD N N 110' CO :;:: C - o .5• cis s o�. .. ..I ' E �f_ g? SPnnS Rill Drive '•ii7 grd MI: ' 6 � js c � 9 A I s °We i� el8iave1) Mai sii 1 1br a m i ii �0 a E t t F _. II I` v 4'. 1,.2 y:L R C : '[Fyy. °. 0 L [�5 nOn m Y I it, i j $I°u 11: ° :' ,.= ND v c I i it a l l dit i $ MW? "1' c ? 3 jiiq F `i i q s 3 ° ___ I i afirti $5,.� 2i ;i;a3 $dr ex Sacdillcm 90 F 2 y= 4u,o F — —LLr I I -< '- ai8ec'a iF#`�i?}, 3 s:. i I _ s ?s ' E ^ ..;.5„ m°m I i I?P..evipg� .r S:{t.€ f;i I Y ` $3 38 4 3 o ! Z' azi MN x ;I [ p: - et s" i --22 fisi arty i n 7, t� it1 $ ^:i7asdai 4 dt - ° i x ., o ¢ Ad : q I` d Ii f �3jl gi:ii,}ia a p al,i a '*a" .�°<a i a x,it if _7 p x, ��� it i} _ � }si-v'i9i 'ii > S IggIo�, -fAS is.`iiiir �e is B72 f�,.� ( � W p8n a V ' 7 a pia _ F I:::- ,` - s j;�. i\ ✓ gZ'x B 1": { * t _ _ AYO 71;tvH0AD(r8' 3 ; ., S �°° -N SR z3s7 pa"eme�t.) £€F€ to ��it, = I a = 2? 1I \ _ 4F yq I = x.. e F: a - b'a ;,g.i i €sill' x anLot r,:e. I, s a o �R s c \ i i 'z$ : 'E ? d ias%i9: 1 tl Ie� F I I Yo P. I St„ > It? i i3g33 a ttat %.,,., m�i iF d3 " _`^ ^\ ,0. o 'aaZasss - L. SI3' o „ 8 \ .� 2 V• aei 9e!k3¢4..• a-a la 13 0 , z ii r g$ t i S, [�c- \ € € .44 oa I 3 O . Y m ■ .yi .g B - ,. 5 ` I x� . 37 I - �yi qQ c t v i �La"ig7 _ e d$ ii., ' _i3 v I} S $i=: ^,i, _v„.00 p \ ifs z^ _ i •I 72 Ic^' ;a2 I ,2A \, •:Eg x , i_z= t i 2 - Str ao its x $ ` v o .0 . i �N pEym _".tea it O - i de"'- i e�� �3-BSSr.� S 1 SSS Catawba County Environmental Health •2 4 ,,\ " � t j ' // Lir g6s y it A Ihkilli,iN11117) 0975 i 6 r °a G G ' 1� : � 5'''.1 . \\I:. ,,•4 fill 1 VS - - alt . ,- , 00, Y . ;I o a. . rt "iu . �pia�yl` ., 4, •• Y �. ,.. ti11 b \ . _„,- 0 . 0 ....."°''''<1 A, (ir 44 tar A 4 d , v - aVIIIIK''' At, oilr re, ., .. 3,4 ti 4 •, , ,,,. .„..,. .. .. , , f ip, „, r . a , .. , , I , ,j \ Parcel: 374309159477, 4274 JA YOUNT FARM 1 in=300ft RD CONOVER, 28613 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 03/01/2016 Parcel Report Page 1 of 1 Parcel Report - Catawba County NC Parcel Information: Owner Information: Parcel ID: 374309159477 Owner: MOORE JIMMY L Parcel Address: 4274 JA YOUNT FARPM-Rd' Owner2: MOORE SHIRLEY C City: CONOVER, 28613 Address: 36 SULLIVAN POINT LN LRK(REID): 64622 Address2: Deed Book/Page: 1145/0492 City: TAYLORSVILLE Subdivision: State/Zip: NC 28681-9786 Lots/Block: / School Information: as Sale: Plat Book/Page: School District: NEWTON CONOVER Legal: RD 1488 Elementary School: SHUFORD Middle School: NEWTON CONOVER Calculated Acreage: 27.620 High School: NEWTON CONOVER Tax Map: 2200 00059 Township: CLINES School Map State Road #: 1488 TaxNalue Information: Tax Rates(pdf) Zoning Information: City Tax District: All in County Zoning District: COUNTY County Fire District: CONOVER RURAL Zoningl: R-20 Building(s) Value: $0 Zoning2: Land Value: $124,500 Zoning3: Assessed Total Value: $124,500 Zoning Overlay: FPM-O Year Built/Remodeled: / Small Area: ST STEPHENS/OXFORD Current Tax Bill Split Zoning Districts: / Zoning Agency Phone Numbers Miscellaneous: Firm Panel Date: 2007-09-05 Building Permits for this parcel. Firm Panel #: 3710374300J Building Details 2010 Census Block: 1018 WaterShed: 2010 Census Tract: 010202 Voter Precinct: P33 Agricultural District: PROXIMITY Parcel Report Data Descriptions List all Owners Deed History Report Assessment Report 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.Tho 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. ir(14 Z `Slo S Co SG\ loci 1--\��//gis.catawbacountync.gov/nomap/parcel_report.php?key=3743091 9477&typ=P 3/1/2016 ys�- f•. a x CATAN'BA COUNTY O ; r - b case ImPV-02-2016.069507 -� �d Public Health Department Tom,_ d}r Subdivision Jimmy L Moore and wife Sh •�' ,'�,' En ironmental Health Division ''' ' ' �- r3 '} PINY 374309150460 ''4- PO Box 389. 100-A Southwest Blvd,Newton.NC 28658 'r LOl'ii 1 -fi . 4.45 . t NAME ON PERMIT: JIMMY L. & SHIRLEY C. MOORE, 36 SULLIVAN POINT LN, TAYLORSVILLE NC 28681 Site Address: 4288 JA YOUNT FARM RD, CONOVER NC 28613 Property Size: Square Feet 153,156.96 Acres:3.516 Directions: County Home Rd, County Home Dairy Rd, right Spring Hill Dr, left JA Yount Farm Rd, property in curve on right Improvement Permit Facility: Primary Residence - house Permit Category: New Septic Bedrooms 5 WATER SUPPLY: Private Well Basement? Yes Basement Plumbing? Yes INITIAL SYSTEM SPECIFICATIONS Permit Valid: Expires In Five Years: _X_ No Expiration: Projected Daily Flow 600 g.p.d Proposed Wastewater System: 25% REDUCTION Type: ItlG -OTHER NON-CONY TRENCH SYSTEMS Permit Conditions: REPAIR SYSTEM SPECIFICATIONS Repair System Required? Required Proposed Wastewater System: 25% REDUCTION Type: 1110 -OTHER NON-CONY TRENCH SYSTEMS Landscaping or other site alterations that potentially divert groundwater or surface water toward the septic system, or prevent proper drainage away from the septic system, including the direction,of gutter flaws or foundation drains, is not approved, and may result in failure to approve the initial system installation,o:the suspension/revocation of existing permits. The issuance of this permit by the Health Department does not guarantee the issuance ol'other pennits. II is the responsibility of the applicant/propeny owner to insure that all C ruvha County Planning/7oning 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 'Laws and Roles far Sewvare Treatment and Distrusts/SI'stem.s' (15A NCAC l8A .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. Steven Price 02/24/2016 AUTHORIZED STATE AGENT APPROVAL DATE 02/23/2021 Permit Expiration Date: No grading or construction activity is allowed in areas designated for system and repair without approval of the health Department. thpennil 02124/2016 16:50 Page 1 of 3 tr•s RN h''+av�flhe4m�i:"s2Ty6'd��fim�1 � 1 a Y, y,T sR; :F'1 1 �'4'r ,:r ' `c, i i we /� r .0 .�4. �SF.( •. • I? PHPA - et- tol(°- 25r37 i!i 88 7A ya...4 F. 9k p• ... sr.& c...i, -Cdt or at;vc ov.r Scion Ceti y s.4 ; I lf' (°P. SM�d J:SiW . �'(- IrstJ 31,0, .n en/.1,4 .14 cr.. M4 kot otex A‘41 L•4 ,....t4 be CtwrAatt :.+r 1. 1n,....ce ♦ F AL. 4111 0 4t 11 a(t. c-/P 0 • N nti FJ, 3 5 V� i4i sc' r �? Scp4t hr... ° 1...k.1 .tttw r u 9 2 b N.1. (wtw� ° .r PY taIn- El(' to Pt I$D e Sv4°w Drr1t.+. 1' • P3 2 751@ 5 5S"u Mile .° 1 71= S° DEPARTMENT OFIW.ALTH AND HUMAN SERVICES (P w12 02-2011.- 23/37 Sheet k of ' DIVISION OF PUBLIC HEALTH,ENVIRONMENTAL HEAL-111 SECTION PROPERTY ID II: To f Ifoybo ON-SITE WATER PROTECTION BRANCH COUNTY: Ce. ...1y SOILISII'E EVALUATION for ON-SITE WASTEWATER SYSTEM (Complete all fields in full) OWNER: """} •'� _ APPLICATION DATE • ADDRESS: DATE EVALUATED: PROPOSED FACILITY: $ a- PROPOSED DESIGN FLOW(.1949): too PROPERTY SIZE: 31-1--`< LOCATION OF SITE: PROPERTY RECORDED: WATER SUPPLY: 0 Private ❑Public gWell ❑Spring ❑Other EVALUATION METHOD: ❑Auger Boring L 'it ❑Cut TYPE OF WASTEWATER: .14.Scwagc ❑Industrial Process ❑Mixed • • • • • e R 0 SOIL MORPHOLOGY OTHER F (.1941) PROFILE FACTORS 1 .1940 • L LANDSCAPE HORIZON E POSITION/ DEPTH .1942 PROFILE x SLOPE% (IN.) .1941 .1941 SOIL .1943 .1956 .1944 CLASS STRUCTURFJ CONSISTENCE/ WETNESS/ SOH, SAPRO RESTR &LTAR TEXTURE MINERALOGY COLOR DEPTH CLASS HORIZ 0— 7 ''Sgk/ cc f,L fe PS ,y,_ 112_ 'IA- "/ GS 7-Sl SOU-/ c FL _re' 1 p? 3(-il'L "S61 / ac fc sr" _ 0 3 U -9 "561C7 cc Fit se �� �� 5 i LS 9-31 set/ c. !� SE" w-'' ern 0.3 2 0.4 3y- co ..564_/ c ft sE 0-4, 'i361L G C e-1�2 E( SC Pr L S (, - (2 56k c. _ Ai se- Lit Am- NA 3 f,'6 (4.-32 c61L c Fa st' o,3 J2- 4L "S.0c G fi Jr • • o- 7 6s,061 e FL f( 1-5 7-41 f6Y/ c id SE n/ 4 y2 .v 0/4- 7.5 4 X0'6 zr-sz Vsnr-/ tL app he 3(---- o •3 • • DESCRIPTION INWALSYSTEM REPAIR SYSTEM OTHER FACTORS(.1946): Available PS SITE CLASSIFICATION(.1948): PS Available Space(.1945) �l/ System Type(s) z Z � 2st 6.1- OTHER(S)HER{S)PRESENT: Ste'', z. Gt2 Site LIAR 0,3 Q,3 COMMENTS: