HomeMy WebLinkAboutEXSY-05-2016-072233.TIF gA CATAWBA COUNTY Case# EXSY-05-2016-072233
2 Public Health Department Subdivision
� K Environmental Health Division PIN# 372419517897
PO Box 389, 100-A Southwest Blvd,Newton.NC 28658 LOP/
/8.2 ,.
NAME ON PERMIT: KOOL PARK SERVICES LLC, 3102 KOOL PARK RD NE, HICKORY NC 28601
Site Address: 3102 KOOL PARK RD NE 64, HICKORY NC 28601
Property Size: Square Peet:540,144.00 Acres:12.400
Directions: From Springs Rd, west on Kool Park Rd NE, approx 1 mile park entrance on right/ home site is next to lot 65
wiich is labeled, location of proposed home and porch is staked
Owner/Authorized Representative Acknowledgement of Permit Receipt
�I certify that I am the owner or authorized agent(owner's authorization required) representing the owner of the
. property described above.
/ `' CS•• As the property owner or authorized representative, I have received the above referenced permit(s) as
requested in t e application for service RBPR-04-2016-23653 by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
Electronic Image Transmittal/E-mail (Return receipt required)
As the property owner or authorized representative I have reviewed and understand the specific conditions
7-
of the permit issued, and further understand that all applicable regulatory requirements specified under the North
Carolina Laws and Rules for Sewage Treatment and Disposal Systems (15A NCAC 18A .1900), and/or
Well Construction Standards (15A NCAC 2C .0100), shall apply to the issuance of this permit and the
construction of the wastewater system and/or water supply well per fitted.
Permit Issue Date: 05/11/2016
caner/Authorized Representative Signature A r
Date
Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature Date/Time
Method: Fax Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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ehpernut OS/1I/2016 09:49 Page 3 of3
see, CATAWBA COUNTY Case# KOOL 04-2016-23653
PARK SERVICES,Name KOOL PARK SERVICES,LLC
2 Public Health Department Address 3102 KOOL PARK RD NE #64
d(a. `j Environmental Health Division
.“°F PO Box 389, 100A Southwest Blvd,Newton NC 28658
1: n• sw (828)465-8270 Fax (828)465-8276 TDD(828)465-8200
EXISTING SYSTEM INSPECTION REPORT
Type of Facility: House ❑ Mobile Home ❑ #Bedrooms 2
Business ❑ Mobile Home Park Re-connection
Other ❑ Specify
Proposed Additions/Accessory Structure:
Approved ® Not Approved ❑ Reason
Approval Not Required—Applicant Request Only ❑
Evidence of System Malfunction: YES ❑ NO 0 System Type/Description
Non Compliance Items Noted YES ❑ NO 0 (Describe Below)
57/6.
AUTHORIZED STATE AGENT DATE
•
Compliance Items and Notes
*4/27/16 visually inspected mobile home park. Lot 17 found to have surfacing effluent. Informed owner and
repairs were made. Reinspected on 5/6/16 and no longer had effluent on surface.
*New mobile home, including decks and porches must be at least 5 ft. from septic tank and drainfield.
*New mobile home will be 2 bedrooms. No guarantee can be given to the septic system's longevity.
*If and when the septic system fails,adequate repair area must be located or the MH must be removed.
*Do not cut,drive, fill,or grade over septic system.
*Mobile home park uses community well.
*Per conversation with the owner,this septic system is not currently in use and this will be the only connection.
NI IT MID I/IAN APPAfIV AI
EXISTING SYSTEM INSPECTION REPORT
Site/System Diagram
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NOT FfIA T IIAN APPAfIV AI