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HomeMy WebLinkAboutEHPR-03-2016-23479 (2).TIF ,y,A � THIS IS NOT A PERMIT Case # EHPR-03-2016-23479 Q CATAWBA COUNTY HEALTH DEPARTMENT 4s' PLAN REVIEW APPLICATION FOR ENVIRONMENTAL SERVICES 1842 sM Environmental Health Plan Review - Repair 4 AUTH CONST- REPAIR Owner RICHARD GILBERT, 4440 SCALYBARK LN, SHERRILLS FORD NC 28673 H:704489297I C:7046166660 HOME:704489297I NAME TO APPEAR ON PERMIT Richard Gilbert SITE ADDRESS: 4440 SCALYBARK LN, SHERRILLS FORD NC 28673 PIN # 460605282928 NAME of SUBDIVISION: Lot 4 Section/Block PROPERTY SIZE: Square Feet 21,780.00 Acres 0.5 DIRECTIONS: HWy 150, Right on Fighting Creek, LEft on Scalybrook, Last house on Left PRIMARY CONTACT: Owner SEWER TYPE: Septic Tank GALLONS PER DAY: 240 WATER SUPPLY: Private Well DESCRIBE WORK: Relocation of Septic tank & pump tank due to addition to the home. Addition will be in 2 areas. 12x16, 32x39. New addition will contain Bathroom & Dining Room &will enlarge an existing bedroom. The# of bedrooms will remain 2. 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? Yes Property Easements Description: 60 foot ROW APPLICATION FOR: Existing Structure STRUCTURE TYPE: PRIMARY RESIDENCE FACILITY TYPE: House OTHER DESCRIPTION: DESCRIPTION OF House, Bldg EXISTING STRUCTURES ON SITE(IF ANY) DIM EXISTING STRUCTURE: House 69x39, Bldg 12x12 NUMBER OF EXISTING BEDROOMS: 2 #OF OCCUPANTS: 2 PROPOSED CONSTRUCTION NEW STRUCTURE DIM:: 12x16, 32x29 BASEMENT? Yes BASEMENT FIXTURES? Yes PLUMBING REQUIRED? Desired system types (Improvement Permit or Authorization to Construct): ACCEPTED: ALTERNATIVE: CONVENTIONAL: OTHER: INNOVATIVE: ANY: YES Other described: E9-ehapplication 03/28/2016 10:15 Page I of4 s CATAWBA COUNTY case# EHPR-03-2016-23479 ¢�' Public Health Department Subdivision Q 114- ,� Environmental Health Division PIN# 460605282928 �``-4® PO Box 389. 100-A Southwest Blvd,Newton.NC 28658 1842 ,:, NAME ON PERMIT: (RICHARD GILBERT), 4440 SCALYBARK LN, SHERRILLS FORD NC 28673 ( Richard Gilbert) Site Address: 4440 SCALYBARK LN, SHERRILLS FORD NC 28673 Property Size: Square Feet 21,780.00 Acres 0.5 Directions: HWy 150, Right on Fighting Creek, LEft on Scalybrook, Last house on Left 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 ace Bible thaj-� mple site ev nation can be performed. Date: f4.A-.Lc_ 2.5-- 2a /G Signature of Applicant or Agent rrz�'t.rc(� ^ 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 t~ {i) i 3; ,„� 4r-�i'1 t'.n 0 P71'1+ I M a0 119:7_:4 (. {N h F I h u'i 1„FEENAME p�.`erth , Lie:jt.: ?:lit; %rDATELiAK IHEE_AMOUNT3�; Authorization to Construct (Repair) Fee 03/28/2016 8300.00 F, MAW t I� isii f0.4 i i 3 is I P _�N lv�l$ TOTAL FFFS 3 E r ” 'f°atar,p ,- kt, al n S3 , 00s r ) ititii +(Fr F. .�.,,.:_....,_. uN p''�._�3.�.i.�38t'F + O�ci+._FE". _h . s.?.y�i�Nji.,i.47�5'. aioLS,+.h,�"_.:�_.._.N_2���_k 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-ehapplicarion 03/28/2016 10:15 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 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 LPL/ q f) 51 ALt/ rA2,; LnJ Subdivision /, eyip; Ll -5 1=o✓'r( d/c Lot# Acres Section/Block/Phase kDriving Directions to Property /-did / f0 / 8;Yk-f OK/ ! • f{kf'Nc C l-'e o C` La PT NAME TO APPEAR ON PERMIT? 'Owner ❑ Applicant ❑ Contractor Applicant Contact Information Name Address Phone Cell Phone Owner Contact Information Name (4 cn d7 C- /b e V r— Address L 4 4 0 5C 41-9, e .—lc L—/J ']`c e rj (=o✓r.-Q Phone 70 f �/� _ Z q q; Cell Phone (70 c 4e1 o Contractor Contact information Name License# Address Phone Cell Phone WHO WILL BE THE PRIMARY CONTACT? )wner ❑ Applicant ❑ Contractor Description of Existing Structures on Site SL; ,'l.+ 6Lr,top Ltv -I o / -A l^I? ✓o,v/^ # of Bedrooms *j' 2. Structure Dimension f. # of Occupants Z Basement act ❑ No Basement Fixtures (]Yes ❑ No 17A I 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 L9"No Does the site contain any jurisdictional wetlands? B J Yes ❑ No Does the site contain any existing wastewater systems? ❑ Yes ErSlo Is any wastewater going to be generated on the site other than domestic sewage? fla"Yes ❑ No Is the site subject to approval by any other public agency? KYes ❑ No Are there any easements or right of ways on this property? Describe(GO j(ow Existing water supply in use 0-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 oft reference) V ❑ Accepted ❑ Alternative nventional ❑ Innovative ❑ Other L7 Any CATAWBA THIS IS NOT A PERMIT COUNTY CATAWBA COUNTY HEALTH DEPARTMENT aApplication for Environmental Services Page 2 Proposed Facility Type ❑ Primary Residence n New Residence ❑ Addition to Residence # of New Bedrooms *j Project Description Structure Dimensions # of Occupants Basement n Yes ❑ No Basement Fixtures n Yes ❑ No Ex. Accessory Describe L ,j1 r ®eYiee 84144Koc 0,-,i,;rI o>L # of New Bedrooms *1- if applicable Structure Dimensions/z.r/ - z;x 2,7 ' 55 3 SPA- )of Occupants 2 Accessory Dwelling ❑ Yes E No Plumbing Q Yes ❑ No Describe Plumbing Needed A.zeyy //po N — n Multi-Family Residence# Units #Bedrooms per Unit*t 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 n 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 ❑ Community Well Abandonment Type n Drilled n Bored ❑ Dug n Unknown Well Repair Requested n Yes ❑ No Describe Calculated Design Flow, Commercial t 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. f 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 7f 1,{ �- La:k— Date iitcf I,�( Z y" Zo(6 . Printed Name of Owner or Agent GGG �� Q ( C,,LG e �_ Catawba County Environmental Health • ,,,,,,,,/ zdeed-V . w 100.1. 43.20 43.36 t 41—p24 2 m 100.1$ t ( a r )4+ '.1 49444- 0"(1� YIIII, ck . N of ! ,,,,,...... .,ik,:I 1' - ir "i're`Tic ' ',raj'''. 60 f ., / likyft,K; ..,:,,,,,,y y ,ss s �s" ya d i'tt ,-av11 til \ii. 1 .s 9 vh s E ' /1a4 , f f i �i fis4a," i ft . ° 4E Ef OA 'b, s ,, # , .t [1:44 , , f`, " _ �s ,a -y U lip �t '1 ye #3 211,1 :;— ti-x�Nag 11 � E + 1 „,124 s h ”. a�i ' z P a m -,; :10.. p /d o . i Yh c? a�. t � �,gy ' vs� a „ t x ATC . 70.40 . � zP pp+ . i ., Sil ° i,a d p,+. £r e f p P 1 g # wy " i . c ilk% 4 ' Tr rbil,L " 7 3''. 2 2 o 3?2 -.1,4n6.99 ..-414,,..t t r'f s s T ia t 5X 1x.Q�r�®r '1Z + t x +, p r P Ai j_ ', : { - ' AN P4. c` f ' 15, h k�( P / j 1. Psi$ a `E a ¢y u iu lift s ' r 1, ..- a pl a: e a ;pi., x c e y-wh, rt .„. g € g , . .,„ .4. 4 k: g � r ys 1 '' 0 ^ t ' 4' ; ` irr ;. F sp r s ,' sE e r v @n + ' t ay 1.∎ 4."0 r 'r ,' 5 ¢ ` . Parcel: 460605282928, 4440 SCALYBARK LN 1 in=5011 SHERRILLS FORD, 28673 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 03/28/2016 Parcel Report Page 1 of 1 Parcel Report - Catawba County NC Parcel Information: Owner Information: Parcel ID: 460605282928 Owner: GILBERT RICHARD LEE Parcel Address: 4440 SCALYBARK LN Owner2: GILBERT HARRIETTE GURLEY City: SHERRILLS FORD, 28673 Address: 4440 SCALYBARK LN LRK(REID): 17784 Address2: null Deed Book/Page: 3281/0701 City: SHERRILLS FORD Subdivision: null State/Zip: NC 28673-8321 Lots/Block: null/ null School Information: Last Sale: Plat Book/Page: School District: COUNTY Legal: null Elementary School: SHERRILLS FORD Middle School: MILL CREEK Calculated Acreage: .500 Tax Map: 017 X 02006B High School: BANDYS Township: MOUNTAIN CREEK School Map State Road #: 2670 TaxNalue Information: Tax Rates(pdf) Zoning Information: City Tax District: All in County Zoning District: COUNTY County Fire District: SHERRILLS FORD Zoningl: R-30 Building(s) Value: $167,700 Zoning2: null Land Value: $120,000 Zoning3: null Assessed Total Value: $287,700 Zoning Overlay: CRC-O,WP-O,FPM-O Year Built/Remodeled: 1975/null Small Area: SHERRILLS FORD Current Tax Bill Split Zoning Districts: null/null Zoning Agency Phone Numbers Miscellaneous: Firm Panel Date: 2007-09-05 Building Permits for this parcel. Firm Panel #: 3710460600J Building Details 2010 Census Block: 4005 WaterShed: WS-IV Critical Area 2010 Census Tract: 011504 Voter Precinct: P41 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. http://gis.catawbacountync.gov/nomap/parcel_report.php?key=460605282928&typ=P 3/28/2016 \)z ■ CATAWBACOUINTY Casc# AUTH-4-II-16825 "tee Public Health Department G 4 Environmental Health Division Subdivision .` 'e PO Box 389, PM.A Southwest Blvd,Newton,NC 28658 Lot 0 t' 2 `" PIN° 460605282928 Applicant/Owner GASSIE GILBERT Site Address: 4440 SCALYBARK LN, Shcrrills Ford.NC Property Size: SF 0_5 ACRES Directions: HWY 150 F NEAR LAKE NORMAN MARINA CROSS BRIDGE,TURN RIGHT AT 1'OP OF HILL,THEN KEEP RIGHT& GO TOWARD THE LAKE.tURN LEFT AT SCALYBARK I.N. HOUSE IS AT THE END OF THE ROAD ON LEFT. (GREEN& WHITE TRIM) Authorization to Construct Permit Authorization to Construct Wastewater System (Required for Building Permiti See site plan and number of additional attachments( ). Proposed Wastewater System: 25% REDUCTION Wastewater Flow ..._ 9__ _ g.p.d Type: IIIB - SYSTEM W/SINGLE EFFLUENT PUMP Soil LTAR: .3 g.p.d./ft2 Permit Category: Repairs Type of Facility: Primary Residence Basement? Yes Basement Plumbing? Yes Bedrooms: 2 Wastewater System Requirements Tank Size: Existing Tank 1,000 gal Pump Tank 1,000 gal Grease Trap gal Dosing Volume gal Pump Specs: GPM @ TDH Pressure Head 2 ft Draw Down in Drainfield: Total Area: 600 sq ft Total Length: 200 ft Maximum Trench Depth 30 in Aggregate Depth in Trench Width 3.0 ft Minimum Soil Cover 12.0 in Minimum Trench Separation 7.0 ft on center Number of Drain Lines 4 Distribution: Pressure Manifold PUMP REQUIRED 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 flows or foundation drains, is not approved, and may result in failure to approve the initial system installation, or the suspension/revocation of existing permits. »»> DO NOT INSTALL SYSTEM UNDER WET CONDITIONS ««< Proposed Repair System Class: Proposed System: Distribution Type:: Soil LTAR: g.p.d./ft2 04/Il/I1 11:04 apa • CATAWBA COUNTY Case N AUTH-4-I1-16825 Public Health Department '1'�2 p Subdivision 4 =, Environmental Health Division ® PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 Lot 4 E0 w PIN/ 460605282928 Applicant/Owner GASSIE GILBERT Site Address: 4440 SCALYBARK LN, Sherrills Ford,NC Property Size: SF 0_5 ACRES Directions: HWY 150 E NEAR LAKE NORMAN MARINA CROSS BRIDGE,'TURN RIGHT AT TOP OF HILL,THEN KEEP RIGHT& GO TOWARD THE LAKE.tURN LEFT AT SCALYBARK I,N. HOUSE IS AT THE END OF THE ROAD ON LEFT. (GREEN& WHITE TRIM) The issuance of permit by the Health Department does not guarantee the issuance of other permits. It is the responsibility of the applicant/property owner to insure that all Catawba County Planning/Zoning and Building Inspections requirements are met. This Authorization to Construct Permit is subject to revocation if the site plan,plat or the intended use changes,or if site conditions are altered. The Authorization to Construct 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 Pones for Sewage Treatment and Disposal Systems' (15A NCAC ISA .1900). Neither Catawba County nor the Environmental I lealth Specialist warrants that the septic tank system will continue to function satisfactorily for any given period of time. Jason Boyd 04/11/2011 AUTHORIZED STATE AGENT APPROVAL DATE Permit Expiration Date: 04/09/2016 No grading or construction activity is allowed in areas designated Jhr system and repair without approval of the Health Department. 04/11/11 11:04 3: Permit# EHPR 3.11-10164 G CATAWBA COUNTY Name Gassie Gilbert '.. .f` 2 Public Health Department Address 4440 Scalybark LN Sherrill's < ,- d Environmental Health Division \. PO Box 389, 100A Southwest Blvd,Newton NC 28658 Ford NC N 828 465-8270 Fax (828)465-8276 TDD(828)465-8200 PINk 460605282928 \8�y w ( ) Site Plan Authorization to Construct Repair 261 r Se- cIYtcr,k Lc. ., 0 w r Lc, t 1nS I� II 0 r i v� P f'�oMt - 1 \pnn �� 51 p7 ,\ ?ems �G 0-0 N\ . , c,� /= \ • ` � of tfK 40 / t r • L. 4ice rn f. 1�� P c \1 p .- I-3 o ;At, t,o re_e c r rn ,n . ( 5 F\ ro erN fV pro (>2_CA 7 tt ^e_j o f Pro,--\ w�l\ n c Lc_ S c, ,, xh.Mk � r Ne.■.J 1 inea -\---b \ok_ t rs-K Ue-0 ors La--.- , ,, r * )0 t, y,,p 1-.D (LI ) Sb ' I nnt-J a5go ►20._a .,L-- , 3 ,\ \ ° oo .D4 \\ r\ f ‘3r„ P -rcrl( rI ; C, 11 Gt-1S -\- cc 2 `t � - 0 43 I LR-lc Scale � %Lt0 fo 1hskcLl � -;0 � } . c�`j �rw, , C �D EI P r 10 r Department of Environment,Health,and Natural Resources Sheet: Division of Environmental Health Property ID: On-site Wastewater Section Lot#: SOIL/SITE EVALUATION File#: for ON-SITE WASTEWATER SYSTEM AppID: EHPR 3-11-10164 Owner: Gassie Gilbert Applicant: Address: 4440 Scalybark LN Sherrill's Ford NC Date Evaluated: 4/611 Proposed Facility: 2 BR Home Design Flow(.1949) 240 Property Size: 1 Location of Site: Property Recorded: Water Supply: Xpublic [ ]Individual X Private Well [ ]Spring [ ]Other Evaluation Method: Auger Boring Pit [ ]Cut Type of Wastewater: X Sewage [ ] Industrial Process [ ]Mixed R , a 'OHM?WHOLOGY b 4 e,i " $991: PROF[LE F�HGTORS t' 41ai 00.66 F6iAt P n 4 � ,� .: . : •.'1942- L .`rlagd�Fap"e&3 o y.0. 9siti r q t941 Soil ,'t$4� ,1956 .21944 Profile E ✓ v, ,ppsttyoq¢x� ae)j cc 4C�egfi Consistence. Wetness/ Soil Sapro, Restr Class .' i .SlopWPL n. r.; e&{ia', • ?■ineralogy Color Depfh(IN - 'Class Ho02 r:'&-:LTAR 1 LL 0-48" SC SS,SP,SEXP,FR 48" 3 2 Description Initial System Repair System Other Factors(.1946): Available Space(.1945) ps Soil Evaluation By: Jason Boyd System Type(s) IIIBG Others Present: Site LIAR .3 Site Classification(.1948): PS Site Evaluation By: Jason Boyd Others Present: Sheet: { - COMMENTS: Existing well on property must be abdandoned prior to installation of repair FILE#: Landscape Position Group Texture .1955 LTAR Structure R-Ridge I S-Sand 1.2-0.8 SG-Single Grain SS-Shoulder Slope LS-Loamy Sand M-Massive LS-Linear Slope CR-Crumb FS-Foot Slope II SL-Sandy Loam 0.6-0.6 GR-Granular NS-Nose Slope L-Loam SBK-Subangular Blocky HS-Head Slope ABK-Angular Blocky CC-Concave Slope III SI-Silt 0.6-0.3 PL-Platy CV-Convex Slope SICL-Silty Clay PR-Prismatic T-Terrace Loam FP-Flood Plain CL-Clay Loam SCL-Sandy Clay Loam {V SC-Sandy Clay 0.4-0.1 SIC-Silty Clay C-Clay Consistence Consistence Mineralogy Moist Wet SEXP-Slightly Expansive VFR-Very Friable NS-Non-Sticky EXP-Expansive FR-Friable SS-Slightly Sticky FI-Firm S-Sticky WI-Very Firm VS-Very Sticky EFI-Extremely Firm NP-Non-Plastic SP-Slightly Plastic P-Plastic VP-Very Plastic Sketch of Soil Evaluation Locations w6 14, Pr ly• JC vu p• CATAWBA COUNTY Case N OP-5-I1-17640 YQ ¢ 2 Public Health Department Subdivision - Environmental Health Division `Ft Q:. PO BON 389, 100-A Southwest Blvd,Newton,NC 28658 Lot W 8• - MVP 460605282928 Applicant/Owner GASSIE GILBERT GILBERT HALL Site Address: 4440 SCALYBARK LN, Sherrills Ford, NC Property Size: SF ACRES Directions: Catawba County Health Department Operation Permit IIIB -SYSTEM W/SINGLE EFFLUENT PUMP System Type: (In accordance with Table Va) Description: 25% REDUCTION Types V and VI systems expire in 5 years. Owner must contact health department 6 months prior to exiration for permit renewal. System Installation Comments: PERMIT CONDITIONS: 1. All maintenance, monitoring, and performance requirements shall be in accordance with 15A NCAC 18.1900, Rule .1961 2. Operation & Maintenance Specifics: Subsurface system operator required? Yes__ No_X_ If yes, see attached sheet for additional operation conditions, maintenance and reporting. 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. Kenny Dellinger 1063 04/28/2011 SYSTEM INSTALLER INSTALLATION DATE Jason Boyd - 41810 05/04/2011 AUTHORIZED STATE AGENT DATE OF OPERATION PERMIT ISSUANCE Form F 05/04/11 10:07 i / bA Permit U OP 5-11-17640 / CATAWBA COUNTY ,.°i' 'Z Public Health Department Name Gassie Gilbert < —"`1I'OPe' H Environmental Health Division Address 4440 Scalybark LN Shertill's aa•; 'C Ford NC � .. PO Box 389, IOOA Southwest Blvd, Newton NC 28658 �8 1, ym (828)465-8270 Fax (828)465-8276 TDD(828)465-8200 PIN# 460605282928 Site Plan Operations Permit .265r sC- CiyL3Cric L—c '\Q__ c0LvGLL fVOM0._ P n4 S T �'7 'Z1`; -,/k V40 NG U_ U \N . C . . f�a / /, . \ o 3 47 Se \ N .\ I / .. � � S. O v % r. '1 i 1 -- Ss+�,n on by Kr--.,� (J � II nyar �ob3 y 1 * M i53 7 , L(^ I-_r PL.Mp C. L 4 - A v (v.f f vOL C) rc1S0- I J IS c.-4 r ,L<c-vrc- LQ.�� (4 ) F . II' r_ -.. r t.vl prtc (Jrt, ■wcv.. Fold !19. 0 Scale ��A CATAWBA COUNTY Y [5t F WIOOASOUTHWESTBLVD NEWTON, NORTH CAROLINA 28658 8658 RECEIPT PHONE: 828.465.8399► / Monday, March 28, 2016 \842 SM www.catawbacountync.gov PAYOR: Gilbert, Richard PAYMENTS TRANSACTION NUMBER: TRC-645194-28-03-2016 PAYMENT DATE : 03/28/2016 PAYMENT TYPE: Check 6593 INVOICE NUMBER FEE NAME FEE AMOUNT 03-16-326518 Authorization to Construct (Repair) $300.00 Fee TOTAL PAYMENTS : $300.00 EHPR-03-2016-23479 CASE TYPE: Environmental Health Plan Review WORK CLASS: Repair SITE ADDRESS: 4440 SCALYBARK LN, SHERRILLS FORD NC 28673 Owner RICHARD GILBERT, 4440 SCALYBARK LN, SHERRILLS FORD NC 28673 H:7044892971C:7046166660 ** NO PEOPLESOFTACCOUNTASSIGNED ** receipt 03/28/2016 10:15 Page 1 of 1