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HomeMy WebLinkAboutEHPR-03-2016-23300 (2).TIF �G THIS IS NOT A PERMIT Case # EHPR-03-2016-23300 rflez •-- : a CATAWBA COUNTY HEALTH DEPARTMENT 0` 4 in u . c { . Ems!' PLAN REVIEW APPLICATION FOR ENVIRONMENTAL SERVICES /842 sM Environmental Health Plan Review - OSWP -r o i� 1 r L• .' IMPROVEMENT Applicant ROBERT PRYSTUP III, 2266 FD RD, VALE NC 28168 H:8284467702 HOME:8284467702 Owner MARY COOK, 1649 DICKINSON RD, HICKORY NC 28602-9002 NAME TO APPEAR ON PERMIT Robert P stu . III SITE ADDRESS: 3561 OLD SHELBY RD, HICKORY NC 28602 PIN # 277002869212 NAME of SUBDIVISION: Lot# 1 Section/Block PROPERTY SIZE: Square Feet 61,855.20 Acres 1.420 DIRECTIONS: Hwy 10 W, right 127 N, left Greed Hwy , right Old Shelby Rd,just before intersection of George Hildebran Rd, across from new green vinyl house PRIMARY CONTACT: Applicant SEWER TYPE: Septic Tank GALLONS PER DAY: 300 WATER SUPPLY: Public Water DESCRIBE WORK: IP only at this time. Existing system on property will not be used. Install new 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? No Are there any easements or right-of-ways on this property? No APPLICATION FOR: New Structure STRUCTURE TYPE: ** NO STRUCTURE SELECTED ** FACILITY TYPE: Business OTHER DESCRIPTION: DESCRIPTION OF EXISTING STRUCTURES ON SITE(IF ANY) DIM EXISTING STRUCTURE: NUMBER OF EXISTING BEDROOMS: #OF OCCUPANTS: PROPOSED CONSTRUCTION NEW STRUCTURE DIM:: 80 x 120 BASEMENT? No BASEMENT FIXTURES? No PLUMBING REQUIRED? EMPLOYEES PER SHIFT: 12 NUMBER OF SHIFTS: 1 TOTAL EMPLOYEES: 12 SEATING CAPACITY: TOTAL FLOOR SPACE (SQ FT): Desired system types (Improvement Permit or Authorization to Construct): ACCEPTED: ALTERNATIVE: CONVENTIONAL: OTHER: INNOVATIVE: ANY: Other described: E9-ehapplication 03/02/2016 10:08 Page 1 of 5 `yt7 CATAWBA COUNTY Case# EHPR-03-2016-23300 f'it ®y,„ Public Health Department Subdivision H Environmental Health Division llg.L) PIN# 277002869212 PO Box 389, 100-A Southwest Blvd, Newton, NC 28658 1842 � NAME ON PERMIT: (ROBERT PRYSTUP III), 2266 ED RD, VALE NC 28168 ( Robert Prystup III) Site Address: 3561 OLD SHELBY RD, HICKORY NC 28602 Property Size: Square Feet 61,855.20 Acres 1.420 Directions: Hwy 10 W, right 127 N, left Greed Hwy , right Old Shelby Rd,just before intersection of George Hildebran Rd, across from new green vinyl house 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 an. I: . I understa that I am solely responsible for the proper identification an labe ing of all property lines and corners and making the site accessibl: 1'at a mpl site ev i n can be performed. Date: ( tP Signature of Applicant or Agent C� An Environmental Health Specialist will contact you within 5 working days of appli on date. If you need further infonnation or assistance please call 828-466-7291 AREA2 s 'k, firnro r - .... .,y) Tr-Poo tor FEENAMEI % ' x__ `s13,7N.R.,DATE rri FEE AMOUNT Improvement Permit Fee 03/02/2016 $150.00 r" 1 •TOTAL FEES;11.111191:11111M' _ ;14 AR4 A 4 5000 t , .,.v ? _.::a.rl s._w.._ 'x5 u.._.-,4a111 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) 09-chapel Hat ion 03/02/2016 10:08 Page 2 of 5 CATAWBA THIS I S NOT A PERMIT counr CATAWBA COUNTY HEALTH DEPARTMENT - „. Application for Environmental Services Page 1 Improvement Permit Authorization to Construct❑ Septic Repair ❑ Septic Malfunction ❑ Septic Expansion ❑ New Well Permit❑ Replacement Well n Well Abandonment❑ Well Repair ❑ Existing System Inspection (Pre-Approval Required) ❑ Application is for New Construction Existing Facility ❑ Property Address 3Sb1 011 Slat Qo Subdivision jA&hary,Nee 0/960a-- Lot# Acres Section/Block/Phase 1< Driving Directions to Property =,' ,,° m 0 - a7 7 ,nJ On .�� NMI. Thrv.� R orrlb old 5k10.1 £ov p a-f 0/kJ of 6-IPebY ('ROSS Qa�- 49t token eovhoy Gbw,v Pl1tL % 2 /'tseohod wii reoicrMlde42u9 and AO ' NAME TO APPEAR ON PERMIT? ❑ Owner E i Applicant ❑ Contractor e f Wei Mope °J 'Ai Applicant Contact Information 6-retie? 9n.a � c /� 6-retie? ✓r9wAt NovsE- Name PogrR-r G I /mil Address 9466 7I RO - 4€316 Phone gag 6 7p a- Cell Phone Owner Contact Information '' I Name `,/e. i t 1% rr J • ft / A-) Cock- E ey / ' II.a/1..to Address a ;—= 0- Phone dela la Cell Phone 008 319 1 a l `t Contractor Contact Information Name License # Address Phone Cell Phone WHO WILL BE THE PRIMARY CONTACT? reOwner ❑ Applicant ❑ Contractor Description of Existing Structures on Site WPM C. ft of Bedrooms *j Structure Dimensions ft of Occupants Basement ❑ Yes ❑ No Basement Fixtures ❑ Yes ❑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 KNo Does the site contain any jurisdictional wetlands? XYes -*No Does the site contain any existing wastewater systems? ( 10414 Tuq 75 c-h3 ( � c�/I1 ❑ Yes Ni No Is any wastewater going to be generated on the site other than domestic sewage?J ❑ Yes IM No Is the site subject to approval by any other public agency? ❑ Yes hSI No Are there any easements or right of ways on this property? Describe Existing water supply in use ❑ Individual Well ❑ Community Well ❑ Semi-Public Well [g County/City/Township Water Line Is a public water supply available? **g 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 ❑ Conventional ❑ Innovative ❑ Other V ❑ Any CATAWBA THIS IS NOT A PERMIT COUNTY CATAWBA COUNTY HEALTH DEPARTMENT North ca;a;;a Application for Environmental Services Page 2 Proposed Facility Type ❑ Primary Residence n New Residence n Addition to Residence # of New Bedrooms *t Project Description Structure Dimensions # of Occupants Basement n Yes ❑ No Basement Fixtures n Yes ❑ No _ Accessory Structure(s) Describe # of New Bedrooms *t if applicable Structure Dimensions # of Occupants Accessory Dwelling ❑ Yes n No Plumbing ❑ Yes ❑ No Describe Plumbing Needed ❑ Multi-Family Residence# Units #Bedrooms per Unit*t 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.)- usiness Specific Type of Business j4a ( , end St , Retail Floor Space #of Employees per Shift a. #of Shifts . ❑ Other Facility Type Specify If Church #of Seats Kitchen n Yes n No If Daycare Specify Occupancy Application for Well Construction/Abandonment/Repair • Proposed Well Type n Individual Well n Semi-Public Well n Community Well . Abandonment Type ❑ Drilled ❑ Bored ❑ Dug ❑ Unknown Well Repair Requested n Yes n No Describe Calculated Design Flow, Commercial t 3 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 lines and corners and making the site accessible so that a complete site evaluation can be performed. Signature of Owner or Agent 1 / Date a' a-7- b Printed Name of Owner or Agent ro 1,eif C r y 41 Catawba County Environmental Health * (226) 221 •7 ..,r 24749 ^rye vS 2442 7� #-° e7163 hel I 553 i / 2 ' —5 i i:"/_-:0/e,:(2•ic,./4 . ,, .• • , / 3561 7�'1 i 168,59 All i t -,4%., / e . i p)/ a_ 41,. .4,---- 4066-el d+\ r, r w 405-96 Z vr 1 ',1%.... - 40 111- -.... irri,„,---"..--"----." , I\) YK: ' '''' ''%***.%'''',,,,N\\\ 7 / i/ mINt c r cv Parcel: 277002869212, 3561 OLD SHELBY RD 1 in=60ft HICKORY, 28602 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 02/22/2016 Parcel Report Page 1 of 1 • Parcel Report - Catawba County NC Parcel Information: Owner Information: Parcel ID: 277002869212 Owner: COOK MARY ANN Parcel Address: 3561 OLD SHELBY RD Owner2: MAYNARD TERRY RAY City: HICKORY, 28602 Address: 1649 DICKINSON RD LRK(REID): 101149 Address2: Deed Book/Page: 3048/1852 City: HICKORY Subdivision: State/Zip: NC 28602-9002 Lots/Block: 1/ Last Sale: School Information: Plat Book/Page: 69/6 School District: COUNTY Legal: LOT 1 PL 69-6 Elementary School: MOUNTAIN VIEW Calculated Acreage: 1.420 Middle School: JACOBS FORK Tax Map: High School: FRED T FOARD Township: BANDYS School Map State Road #: 1002 Tax/Value Information: Tax Rates(pdf) Zoning Information: City Tax District: All in County Zoning District: COUNTY County Fire District: MOUNTAIN VIEW Zoningl: RC Building(s) Value: $0 Zoning2: Land Value: $19,200 Zoning3: Assessed Total Value: $19,200 Zoning Overlay: Year Built/Remodeled: / Small Area: MOUNTAIN VIEW Current Tax Bill Split Zoning Districts: / Zoning Agency Phone Numbers Miscellaneous: Firm Panel Date: Building Permits for this parcel. Firm Panel #: Building Details 2010 Census Block: 1013 WaterShed: 2010 Census Tract: 011801 Voter Precinct: P24 Agricultural District: 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.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. ©2016, Catawba County Government, North Carolina. All rights reserved. X30 ��� , 300 GPP � u_A - Lt f C e4 sits Sy ie-ri --. (-v bcINsjuticd http://gis.catawbacountync.gov/nomap/parcel_report.php?key=2 7 7002 8 692 1 2&typ=P 3/2/2016 1 , r", • r,. CATAWBA COUNTY HEALTH DEPARTMENT A, C I .. . )oti.../7. NEWTON, NORTH CAROLINA • COMPLETION PERAIIT OR SEPTIC TANKS t , 1,1 PERMIT # C — ( . - . • AT . • 1 ADDRESS , . BUILDING CONTRACTOR SUBDIVISION • I ... leey . / - 6 ,?.,,,,7Ate- \C LOCATION , 00t.rgel... 0-7.. /I/9a720/131 40t-e-l_ - , OT # -../ . LOT SIZE .. BLOCK OR SECTION • 1 HOUSE ( ). MOBILE HOME NI sus.INEss ( ) OTHER. ( ) FHA-VA LOAN I - SEPTIC, TANK: (SIZE /tC)C) GALS) WATER SUPPLY NO., BEDROOMS .2..- NO FIXTURES ( ' INDIVIDUAL K PUBLIC 1 ' GARBAGE DISPOSAL UNIT:YES ( ) NO ( X IF WELL , TYPE: BORED DRILLED I DUG AUTO WASHING MACHINE,: YES ( 15. NO ( ) DISTANCE FROM SEPTIC TANK OR NEAREST • • NITRIFICATION FIELD : go 0 SQ.,FT . POLLUTION: IOU • • I FT..•• 1) NUMBER OF LINES 9 SEPTIC TAle , T T LED BY : I ' 2) LENGTH AND WIDTH OF LINES - ire---7----,--' LS K 6 6 . PERmiT FEE $ a) BED SYSTEM (K) CERTIFICATE OF C LETION BY : • 1 . .b) TRENCH SYSTEM ( ) ,... -,.......,,, . I .------ . ...).-:-.DERTIL-O.F.,.,STONEnrIN,-L INE S. ./..U....,----,..... • ADEQUATE FALL (GRADE) ON : „ // -• 1) BUILDING (HOUSE), SEWER LINE : I YES cC) NO ( •) 2) NITRIFICATION LINES : DATE INSTALLED : y1/4” rii • ' YES (‘7) NO ( ) •SEPTIC TANK LAYOUT 1 , . . 1 H - t . • 00 i - i___ . p4 = , . F . H . H 0 • '\ • . . A, HEALTH DEPARTMENT COPY P 7 IMPROVEMENT PERMIT'FOR SEPTICTTANKS , J Permit No. l 2376 her /� AME OF OWNER MCC r,.t l ,DATE 7 r 'ti DDRESS OF OWNER 1 g 4o r�` '' '� .3s(i�4 PHONE ME OF CONTRACTOR . ADDRESS OCATION ( iO4-54 aJ UBDIVISION LOT NO SECTION OR BLOCK OT SIZE FHA, VA LOAN OUSE ( ) MOBILE HOME ()C) BUSINESS ( ) OTHER ( ) SEPTIC LAYOUT O. BEDROOMS (2) N0. FIXTURES (f ) ARBAGE DISPOSAL UNIT: YES :( ) NO QQ LUMING UNDER BASEMENT FLOOR: YES ( ) NO Ii() IZS` OF TANK ,/00 LIQUID GALLONS ITRIF•ICATION'FIELD: . 1. Number, of lines. 3, 2. Length and width of lines: a. Bed System /5' K f' Q ft. b. Trench system ft. 3. Total Depth of stone 7f) inches ROUNDWATER INTERCEPTOR DRAIN: into f- fi`42 (IF REQUIRED) ATER SUPPLY: PRIVATE 09 PUBLIC ,( ) dNER NOTIFIED CHECK ZONING. YES (K) NO ( ) 4NER AGREES WITH LAYOUT: 'YES '.(x) NO ( ) WNER AGREES. WITH SPECIAL INSTRUCTIONS •YESQ() NO ( ) 4NER OR. CONTRACTOR SIGNATURE QQp I ERMIT FEE $ 357c----L" , S/ l ERMIT VOID AFTER 36 MONTHS l ' 11PROVEMENT PERMIT. ISSUED BY SEPTIC TANK CONTRACTOR MUST FOLLOW ALL DETAILS OF THIS PERMIT (LAYOUT) ANITARIAN HEALTH DEPARTMENT COPY JIL CLASSIFICATION: SUITABLE ( ) PROVISIONALLY SUITABLE i(NC-) UNSUIT_ABLE ( ) CTE FACTORS c . . SLOPE (7) $ - PS - U 7. SOIL PERMEABILITY S -(E) . SOIL TEXTURE (12-48 IN.) S U ' UNDER 60 MIN. - OVER 60 MIN:. _ SANDY, LOAMY, CLAYEY -� 8;: OTHER S - PS - . SOIL STRUCTURE (12-48 IN:-) S - 6 - !Ur ' (SPECIFY) 1 . SOIL DEPTH (IN. ) " S - . - U 9. SOIL SERIES RESTRICTIVE HORIZONS (IN'.) S _. a - U A. CECIL ( ) B. HIWASSEE ( I) (IMPERVIOUS STRATA, ROCK) C. MADISON ( ) D. APPLING ,( j:): • SOIL DRAINAGE - GROUNDWATER S - U E. PACOLET ( ) F. FLOOD PLAIN ( ) (EXTERNAL - INTERNAL) G. 2-1 CLAY SOIL. H. OTHER-SPECIFY 1------C\ CATAWBA COUNTY 100A SOUTHWEST BLVD NEWTON,NORTH CAROLINA 28658 RECEIPT V" V►�� PHONE: 828.465.8399 \U " fi �e►7 Wednesday, March 2, 2016 ;ifs.• \s 411 SM www.catawbacountync.gov PAYOR: Prystup III, Robert PAYMENTS TRANSACTION NUMBER: TRC-630269-02-03-2016 PAYMENT DATE : 03/02/2016 PAYMENT TYPE: Credit Card 158742065 INVOICE NUMBER FEE NAME FEE AMOUNT 03-16-325757 Improvement Permit Fee $150.00 TOTAL PAYMENTS : 5150.00 EHPR-03-2016-23300 CASE TYPE: Environmental Health Plan Review WORK CLASS: OSWP SITE ADDRESS: 3561 OLD SHELBY RD, HICKORY NC 28602 Applicant ROBERT PRYSI'UP III, 2266 FD RD, VALE NC 28168 H:8284467702 ** NO PEOPLESOFTACCOUNTASSIGNED ** Owner MARY COOK. 1649 DICKINSON RD, HICKORY NC 28602-9002 receipt 03/02/2016 10:08 Page 1 of 1