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HomeMy WebLinkAboutEHPR-03-2016-23523 (2).TIF 4.i'\gA •� THIS IS NOT A PERMIT Case # EHPR-03-2016-23523 t.,-;KrI3A0': , , 1 CATAWBA COUNTY HEALTH DEPARTMENT O P .• ti . O J PLAN REVIEW APPLICATION FOR ENVIRONMENTAL SERVICES I a ; 842% Environmental Health Plan Review - OSWP • • do REPLACE WELL � 0_ , f • . I Owner STEVEN BROWN, 206 N HAWTHORNE RD, WINSTON SALEM NC 27104 C:3366926766 NAME TO APPEAR ON PERMIT Steven Brown SITE ADDRESS: 6918 LOCKE DR, SHERRILLS FORD NC 28673 PIN # 369702997877 NAME of SUBDIVISION: RODNEY WHITE LAKE MAP 2 Lot# 19 Section/Block PROPERTY SIZE: Square Feet 25,264.80 Acres 0.58 DIRECTIONS: NC Hwy 150, Left on Mt Pleasant Rd, Left on Locke Dr, 1/2 mile on Right. PRIMARY CONTACT: Owner SEWER TYPE: Septic Tank GALLONS PER DAY: 600 WATER SUPPLY: Private Well DESCRIBE WORK: Replacement well. `No Water currently 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: Existing Structure STRUCTURE TYPE: PRIMARY RESIDENCE FACILITY TYPE: House OTHER DESCRIPTION: DESCRIPTION OF House EXISTING STRUCTURES ON SITE (IF ANY) DIM EXISTING STRUCTURE: 40x61 NUMBER OF EXISTING BEDROOMS: 5 #OF OCCUPANTS: 1 PROPOSED CONSTRUCTION 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: APPLICATION FOR WELL CONSTRUCTION PROPOSED WELL TYPE: Individual Well REPLACE WELL?: YES L9-ehappllcation 03/31/2016 09:57 Page I of 4 0,A CATAWBA COUNTY Case# EHPR-03-2016-23523 - G Public Health Department Subdivision t. RODNEY WHITE LAKE MAP 2 < ��2;II Environmental Health Division PIN# 369702997877 '^+ PO Box 389. 100-A Southwest Blvd,Newton.NC 28658 1842 v._ NAME ON PERMIT: (STEVEN BROWN),206 N HAWTHORNE RD, WINSTON SALEM NC 27104 ( Steven Brown) Site Address: 6918 LOCKE DR, SHERRILLS FORD NC 28673 Property Size: Square Feet 25,264.80 Acres 0.58 Directions: NC Hwy 150, Left on Mt Pleasant Rd, Left on Locke Dr, 1/2 mile on Right. 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. Authorize ounty and state officials are granted right of entry to conduct necessary inspections to determine compliance with applicable laws and rules. I and sta at I am solely responsible for the proper identification anddlabelin of all property lines and corners and making the site acce I le so that a co p to site ev. aluation can be performed. Date: 3 1 t k I Signature of Applicant or Agent d---------_____ An Environmental Health Specialist will contact you within working days of application date. If you need further information or assistance please call 828-466-7291 AREA1 tzert E , v e ` r,� 5'1,441:0111:1"I Fisk ', 'I [f. is`#'s. a l'"tt�' 4,,,f r nt DATES `I ' FEEA MOUNTu.4 Well Permit& Inspection Fee 03/31/2016 $300.00 f .k TOTAL FEES :r ,q - 4 tt111/, -..:-T;inn.5`tti� trt $3O(IrOO °` I L iSiii 1i.tit i 4 aiii a'a»I 0ild/ t .-..--..._ _// / , __.....--_...,...3 S. t.n c`'n-w .«F-? .'.,,.. °,ev.- ....._. 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 03/31/2016 09:57 Page 2 of4 c T \VB e THIS IS NOT A PERMIT COUNTY ,� , CATAWBA COUNTY HEALTH DEPARTMENT `''41'..NR North .. Application for Environmental Services Page 1 Improvement Permit n Authorization to Construct❑ Septic Repair Septic Malfunction ❑ Septic Expansion I New Well Permit n Replacement Well . Well iz Abandonment n Well Repair E. Existing System Inspection (Pre-Approval Required) n Applicatio n is for New Construction ❑ Existing Facility'" *Property Address (.0 Gj t SI La Lt 15.a- Subdivision $ KR J f-LL s 4029 r� c„i &-6 -1 3 Lot# Acres Section/Block/Phase Driving Directions to Property NcIS0 ( -� 0 „ 0-" rP( ,a -0.1 lispAt- ____ Lc, c_. -e NAME TO APPEAR ON PERMIT? Owner n Applicant n Contractor Applicant Contact Information Name r " Address ) '�-0 fb /'\ �—t�'1-,-�-�'17-.,.�r ,.)•c AO (-Li'-`-- �'- c- A/r\ A,L Phone / Cell Phone ar7/ o)L Owner Co tact Informatio • Name eJft ,/ Address (r, of f Logy /cam .0 r, S/ h r� r ( Bern v,J c- D' C- ? 3 Phone Cell Phone 3 '? (o to et G 7 ( (, Contractor Contact Information Name License # Address Phone Cell Phone WHO WILL BE THE PRIMARY CONTACT? Owner ❑ Applicant n Contractor Description of Existing Structures on Site f�-c� v S # of Bedrooms *i �� Structure Dimensions # of Occupants Basement CyYes n No Basement Fixtures 111-Yes ^ No '2 The Applicant shall notify the local health department upon submittal of this application if any of the following apply to the property question. If the answer to any question is "yes", applicant must attach supporting documentation. Yes ¶No Does the site contain any jurisdictional wetlands? Yes a No Does the site contain any existing wastewater systems? ❑ Yes l 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? ❑ Yes -o No Are there at asements or right of ways on this property? Describe Existing water supply in use Q Individual Well n Community Well n Semi-Public Well ❑ County/City/Township Water Line Is a public water supply available? ** ❑ Yes n 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 ❑ Any CATAVV EA THIS IS NOT A PERMIT COUNTY • CATAWBA COUNTY HEALTH DEPARTMENT G„ Application for Environmental Services Page 2 • Proposed Facility Type ❑ Primary Residence ❑ New Residence in Addition to Residence #of New Bedrooms *t Project Description Structure Dimensions # of Occupants Basement ❑ Yes n No Basement Fixtures ❑ Yes ❑ No n Accessory Structure(s) Describe # of New Bedrooms *t if applicable Structure Dimensions ft of Occupants Accessory Dwelling ❑ Yes n No Plumbing ❑ Yes n No Describe Plumbing Needed ❑ 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.) ❑ Business Specific Type of Business Retail Floor Space # of Employees per Shift #of Shifts ❑ Other Facility Type Specify If Church # of Seats Kitchen El Yes ❑ No If Daycare Specify Occupancy Application for Well Construction/Abandonment/Repair Proposed Well Type Xlndividual Well ❑ Semi-Public Well n Community Well Abandonment Type n Drilled ❑ Bored ❑ Dug ❑ 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. 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 perforated. Zo1 Signature of Owner or Agent � r� n ( In- C_d Date ( Printed Name of Owner or Agent y ic J E t�LC-0 —J Catawba County Environmental Health 4444° y sk d, a° j- ° .L biy �a 'l Y, . dp�`-�r„"."�es ra ,.n ? ��14 3 S4414 3 ' W4 it' t.� It07.44fIY fi i, ,4 . ,a 'fl ay' . 4.;71r w 'i98� m'br4 tb , .4 ,Je 'd �¢4.e t xr ,w` � t � . ,... 's,.7 ,aa .e. .r,9,y y5 't w as n cd+ yte>y .¢y, t , 5 : d } W f-€fi 'yi fl 9� � .at5 �. A4O0040.00�0 Sai�'�� T}� �� "x h h �9 � "r.e, pV`vp ec 1,4+e 4441111;"a -, "10 4 Go$ b¢ 9 tF 41 n, c a 1 > ^k ,w¢y° b ^a a'a alb 9 i �'a 04 "v,+ .,alb yin , r. k- 4 nad '.. t'u pg . t ` 4 C . 7" n'll V' ^4jQ��a C '7 9,P � . If 3a§' v'8 rte' i` prgl 3"Pant x ,ary s� 8 kt n sn..tr .r r w a�2 ti :," �ya�G , e yx�.�R�2�p f &'' e���`"`�#� R" 3R ws����" � s �. � �.ardNkali o y v :i L �> e v`Fri ep t'�d d s k . n3dn' sit ¢ . . +z ate,¢ ' cur. 4� t p %,,,,:b6,01- a,�ss,�"�s !�� � i 4,9'1¢k' �'x'c!y�c'�' .+�b4s�b� ?mil .+' �r .; 4E 's 411 4b ¢ ea"2,4';t b 1b. a tb ate`,'. �,^. ' �� 1 , Cn K -,..1444., f.,..,..,2:,.... # to yti, e . Willr,111 12830 ig, .40 00 . 77 30.0 r 4260, /1/7 100.00 . ( Oe h (385) 4 -W4 lis 771 7100 a 14.40 IS cr N \Its Parcel: 369702997877, 6918 LOCKE DR 1 in=50ft 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 03/31/2016 Parcel Report Page 1 of 1 Parcel Report - Catawba County NC Parcel Information: Owner Information: Parcel ID: 369702997877 Owner: BROWN STEVEN W Parcel Address: 6918 LOCKE DR Owner2: BROWN DANA City: SHERRILLS FORD, 28673 Address: PO BOX 10200 LRK(REID): 6316 Address2: null Deed Book/Page: 2983/0596 City: MATTHEWS Subdivision: RODNEY WHITE LAKE MAP 2 State/Zip: NC 28106-0220 Lots/Block: 19/ null Last Sale: $306,000 on 2009-07-17 School Information: Plat Book/Page: 12/15 School District: COUNTY Elementary School: SHERRILLS FORD Legal: null Middle School: MILL CREEK Calculated Acreage: .580 Tax Map: 006AX 01018 High School: BANDYS Township: MOUNTAIN CREEK School Map State Road tf: 1932 Tax/Value Information: Tax Rates(pdf) Zoning Information: City Tax District: All in County Zoning District: COUNTY County Fire District: SHERRILLS FORD Zoning1: R-30 Building(s) Value: $171,500 Zoning2: null Land Value: $132,700 Zoning3: null Assessed Total Value: $304,200 Zoning Overlay: CRC-O,WP-O,FPM-O Year Built/Remodeled: 1974/2009 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 it: 3710369700J Building Details 2010 Census Block: 3004 WaterShed: WS-IV Critical Area 2010 Census Tract: 011501 Voter Precinct: P31 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.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=369702997877&typ=P 3/31/2016 �A C CATAWBA COUNTY 100A SOUTHWEST BLVD yNEWTON,NORTH CAROLINA 28658 RECEIPT '� �► PHONE: 828.465.8399 \V , d0r *-C Thursday, March 31, 2016 s 4'v sm www.catawbacountync.gov PAYOR: Brown, Steven PAYMENTS TRANSACTION NUMBER: TRC-646936-31-03-2016 PAYMENT DATE : 03/31/2016 PAYMENT TYPE: Credit Card INVOICE NUMBER FEE NAME FEE AMOUNT 03-16-326689 Well Permit& Inspection Fee $300.00 TOTAL PAYMENTS : $300.00 EHPR-03-2016-23523 CASE TYPE: Environmental Health Plan Review WORK CLASS: OSWP SITE ADDRESS: 6918 LOCKE DR. SHERRILLS FORD NC 28673 Owner STEVEN BROWN.206 N HAWTHORNE RD, WINSTON SALEM NC 27104 C:3366926766 ** NO PEOPLESOFT ACCOUNT ASSIGNED ** receipt 03/31/2016 09:57 Page 1 of I