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HomeMy WebLinkAboutEHPR-05-2016-23937 (2).TIF �qA THIS IS NOT A PERMIT Case # EHPR-05-2016-23937 c� r't'°El , ' r Q — irl CATAWBA COUNTY HEALTH DEPARTMENT �' - no � � � !' 7 PLAN REVIEW APPLICATION FOR ENVIRONMEN"CAL SERVICES . c ir 2 $ 184A1 Environmental Health Plan Review - OSWP do ' o r ti- o. a! IMPROVEMENT- AUTH CONST- EXPANSION a• n f,o r\tV cdgIgIll.o - \bely110Lifrw Applicant LAKE VISION DEVELOPMENT (JODINA PRAUTO), 2242 LONGCOVE CT, SHERRILLS FORD N 28673 JODI@LAKE VISIONDEV ELOPMENT.COM Contact Person LAKE VISION DEVELOPMENT (JAN PIZZUTO),2242 LONGCOVE CT, SHERRILLS FORD NC 2 C:70488091I8 Contractor *LAKE VISION DEVELOPMENT INC (PHILLIP ROTELLA), 2242 LONGCOVE CT, SHERRILLS F NC 28673 B:7045060807 C:7045060807E:8289940919 PHIL@LAKEVISIONDEVELOPMENT.COM Owner SEAN& MICHELLE ROUNDS, 3971 CHEVLOT HILLS RD, SHERRILLS FORD NC 28673 C:7042580307 NAME TO APPEAR ON PERMIT *LAKE VISION DEVELOPMENT INC (Phillip Rotella) SITE ADDRESS: 3971 CHEVLOT HILLS RD, SHERRILLS FORD NC 28673 PIN # 460715636672 NAME of SUBDIVISION: CRESCENT LAND AND TIMBER Lot# 110 Section/Block PROPERTY SIZE: Square Feet 29,620.80 Acres 0.68 DIRECTIONS: Weston Hwy 150, Right onto Cheviot Hills Rd, 1st Left (Cheviot Hills), 2nd house on Left. MARY CONTACT: Contact Person SEWER TYPE: Septic Tank GALLONS PER DAY: 480 WATER SUPPLY: Private Well DESCRIBE WORK evise /14/16 - Chanend tooaa total of•4 BdRms 480 GPD) y ave a 3 BdRm permit Ile for house. Wanting to expand the septic to 5 BdRms. Not expanding the footprint of the home. Rooms in the existing house could potentially be classified as BdRms. 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 & Shed EXISTING STRUCTURES ON SITE (IF ANY) DIM EXISTING STRUCTURE: House 104x60 NUMBER OF EXISTING BEDROOMS: 3 #OF OCCUPANTS: 5 PROPOSED CONSTRUCTION NEW STRUCTURE OWL No Addition C#OF NEW BEDROOMS:: 1`, 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: P9-ehapplication 09/14/2016 15:44 Page 1 of 4 �A G THIS IS NOT A PERMIT Case # EHPR-05-2016-23937 lR' �J;� CATAWBA COUNTY HEALTH DEPARTMENT U ro ; D (3Mter.9 PLAN REVIEW APPLICATION FOR ENVIRONMENTAL SERVICES 1842 s�� Environmental Health Plan Review - OSWP I9. 'o _ .o t IMPROVEMENT - AUTH CONST- EXPANSION .o } d o f • Applicant LAKE VISION DEVELOPMENT (JODINA PRAUTO),2242 LONGCOVE CT, SHERRILLS FORD N 28673 JODI@LAKEVISIONDEVELOPMENT.COM Contact Person LAKE VISION DEVELOPMENT (JAN PIZZUTO), 2242 LONGCOVE CT, SHERRILLS FORD NC 2 C:7048809118 Contractor *LAKE VISION DEVELOPMENT INC (PHILLIP ROTELLA), 2242 LONGCOVE CT, SHERRILLS F NC 28673 6:7045060807 C:7045060807F:8289940919 PHIL @LAKEVISIONDEVELOPMENT.COM Owner SEAN R.MICHELLE ROUNDS, 3971 CHEVLOT HILLS RD, SHERRILLS FORD NC 28673 C:7042580307 NAME TO APPEAR ON PERMIT *LAKE VISION DEVELOPMENT INC (Phillip Rotella) SITE ADDRESS: 3971 CHEVLOT HILLS RD, SHERRILLS FORD NC 28673 PIN # 460715636672 NAME of SUBDIVISION: CRESCENT LAND AND TIMBER Lot It 110 Section/Block PROPERTY SIZE: Square Feet 29,620.80 Acres 0.68 DIRECTIONS: West on Hwy 150, Right onto Cheviot Hills Rd, 1st Left(Cheviot Hills), 2nd house on Left. PRIMARY CONTACT: Contact Person SEWER TYPE: Septic Tank GALLONS PER DAY: 600 WATER SUPPLY: Private Well DESCRIBE WORK: Currently have a 3 BdRm permit on file for house. Wanting to expand the septic to 5 BdRms. Not expanding the footprint of the home. Rooms in the existing house could potentially be classified as BdRms. 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 & Shed EXISTING STRUCTURES ON SITE (IF ANY) DIM EXISTING STRUCTURE: House 104x60 NUMBER OF EXISTING BEDROOMS: 3 #OF OCCUPANTS: 5 PROPOSED CONSTRUCTION NEW STRUCTURE DIM:: No Addition #OF NEW BEDROOMS:: 2 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: E')-ehapplication 05/24/2016 10:16 Page 1 of4 cy,• CATAWBA COUNTY Case it EHPR-05-2016-23937 .v rag Public Health Department Subdivision CRESCENT LAND AND TIMBE < , y '� Environmental Health Division PIN# 460715636672 � PO Box 389, tOO-A Southwest Blvd,Newton,NC 28658 /g.2 s. NAME ON PERMIT: *LAKE VISION DEVELOPMENT INC ( PHILLIP ROTELLA), 2242 LONGCOVE CT, SI-IERRILLS FORD NC *LAKE VISION DEVELOPMENT INC ( Phillip Rotella) Site Address: 3971 CHEVLOT HILLS RD, SHERRILLS FORD NC 28673 Property Size: Square Feet 29,620.80 Acres 0.68 Directions: West on Hwy 150, Right onto Cheviot Hills Rd, 1st Left (Cheviot Hills), 2nd 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 identifica is and abeling of all property lines and corners and making the site accessible so that a complete site evaluation can be performed. Date:Th q J �Lp Signature of Applicant or Agent e—a t 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 i9FiEEN'A`MEr�I) In �+^t i ,IltJillPtl ( i P i?I,i1 iiljL11II Gi1111�1' DATEaIll�dj EEEAMOUNTj] Authorization to Construct Fee (New/Expansion) 05/24/2016 $300.00 Fee Improvement Permit Fee 05/24/2016 $150.00 7 ni;n 'l .gTOTAL�FEES ?i�l'��8f11�11'lh' IiIN�� n ";"` ��� i , g: �I Ii811111t ,s456:0411 h� il�ll�ll� IH 1 �I�kN 1:4`e vit IU114lllllllltl(rwai4,.avaiWICIII111PWI:U,no• - a.u1d„IUx.,r 3inallt4U ieliwlwilt.• / 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-ehappl ical ion 05/24/2016 10:16 Page 2 of 4 --ativizter::::,&rara a CATAWBA CODNTY,KEALTH DEPARTMENT Por Page I . Inileovenunst:PcrmiftW Antin).rization.,to Construct El Septic Bepair..0. Septic,Malftinction0 SePtie.EXitanairin Permit 0.12ephicenteni Well 0 Well Abandon ment.0 • Well Repair ci :,E4sting System Inspection (Pro-Approval Required) 0 Application:is for New Construction 0 Existing Facility'0 Property Address/599 I CheVierk, NAOS Subdivision eini- is.bw Di 3 Loll/ tiO Acres : Section/Block./Phise- . Drhting Directions to Property NAME TO.APPEAR ON.PEBMITT 0 °Into. 0 Applicant fg COntraCtor Applicant,Contact'Information NaM6111.14P' Vkcvv bare-197AI enc Addrcssqy trfsntlittfr. CA .tierictic;fled Mr 2.93toci Pi°g€10-1--c161-Dtie0-3 Cell Phone lOWiter cofitaet Intonation NarOcSen(3.it Rib( lAddress"?)il I (*ISE ,r,S1tit1c Toed NC. zziNem Phone ri , • Cell(Phbne CoritrictOr.Contact Information 144*Lake, 'Iiciãn brior..leeft"trY1F (in rcR aulth Address 2.2s12- LooToNte C4. ":•bkeirillsT-Or"ii NC: Th&i3 Phone I Cell'Ph9Oe.9 r Mb—%t is WHO WILL BE Tile PRIMARy,CONTACT?. 0 Owner, 0 Applicant Description of Ex isting'StrnetureSbnSitO'clitel'f?iiin:iu Mika kç4 I chief'?" #ofBedmoms 't3 SonCare ons (d) #otOccuparns: Basement 'Yes D No Basement Fixttlft laYes 0;140 The Applicant shall:notify thabXailhealth'department;upon sutithinal'of this application any of thi.fellocVingtapply to the property in question lithe int:Wei:4o any question is 'yes",applicant must amicifisupporting documentation 13 Yes 12!;No Does the site contain any jurisdietidnaliWedands7 Er Yes 0 No Does the siteetiatain any rusting wastewater:Sy.steMs7 O Yes :O.N0 is any wastcWater going to be generated on the site other than'doinestiCieWage7. ltifNo As the site subject tO amiroval,by any other publie;agcriey7 O Yes; ; 10o Are there any easements or right of ways on this property? Describe Existing water supply use 1St Indiiidtial:Well UptimMUnitY(Well U SeMiE:PublieNicli, it),bourtlyieitj;ttownship Voter Line Is a pub!?Water sUppfrayailable? **.0 Yes U No 114pplying.foe an IMprovement_permit or Authorization to Construct,rko,oeindicatiPesired;SYstetifTYpc(s): (systems can be ranked in order of your preference) ID Accepted. 0 Alternative bonventional U InicOatitiie 0 Other 0,Any. �,r�lnvv ii)4 l� uti � CATAWI3A COUNTY I•IEAI,IH'll EPA RTMENT: ,,,.„,a.;,,.,. Application for Environmental Services Paget Proposed Ractlity 1)per.., ❑Jpia.6 Residence 0 New Rsidenee 0 Addition to Residence i/of New Bedrooms "t Project Dcseription' :Suimitii'e Dimensions It of Occupants , Basement, ® Yes^.CI No I Basement Fixtures C ,Yes (3 No' Lf'`Acecasorystrtiefare(s) Describe It of New;,Redroorrits'et tf a PP°'lieable Structure Dimensions • It of Occupants Accesso Dwell ry g;'®Yes ❑,No••Plumbing?,®Yes D No . Describe Plumbing Needed. Multl-Fatti.ilyRResldenea4 Units" #Bedrooms per;Uiiit't, -Total i Bedrooms'• Structure.Dimensions ❑`.Food Service: 'Specify Type . tY Scats' FloorfSpacc•Entire Food Service Facility(Sq Ft): t1 Employees per,Shift . d of Shif , Dining,'Atea(Sq;Ft:) U"Business Spociltc Type of,Businerss"• - __ Relad Floor SpaceP' R of,Ettiployees perShift.• //Of Shifts., - Other Faclllt';T e S-ecif 2 t ,� a e' �i Y y'P" P Y �... � tea`. ,u � '' �_, .. . 'AP'44 ,s.: 4114_ ,, :1f Church,.11;of Seats • Kitchen.0 Yes• QNo If Daycare v$Pecify Occupancy • Application far-Well Coiutrncttou/Atiaodunment/Rejralr` Proposed\Vell Type ❑ ludnidual"Well ❑•Semi-Public•lVell ❑Community Well .AbandonmenT yp e ❑ I ❑� Borod ❑.Du g ❑ Unknown' Well Repair Requested t8 yes: No Descnbc; Calculated Desigi;Flow, Comrnert alt. Additional information;may be required to dcttrmine- design flow from certainfacilittes This value Htll be determined dung consultation with on-site atafg, _ 'Any roam that will.be intended for sleepmg,at the time of canstnietion'or,for future consideratioin should be noted as a bedroom end,• counted on all applications The number of bedrooms will be eunfur reed by rooms identified,an House plans es a•bedrooin"at the tune of build' !t!B petmu issuance. This lnay pn.ventihe nocd.foa•;septic system size inaaist in lhc•fuiure:' t If sn alai is plumbed but;no bedroiim&'calculated design f ow isrcquir d.. "lfNo,a well permit must be issued withlhe'Authorization to Caustruct SYSTEM REDESIGN AND/OR RETRIP WILL"INCUR AN.ADDITIONAL CHARGE;(SEE-FEESCIIEDIII,E) Improvement Permits issued as a result of this information are valid for 5 years pr may be specified conditions.An Auihanzanott to Construct issticd by they deParunenl is valid•ice 5);f ve ( years from ilia date issued and is not- tiansfcrable Improii n&tt Pcrmitsand Will Permits are tnuiisfcbable: Permits maybe revoked:iithe information on this;application, a.. site pliits'or.mtentfed use changes for the pr$posed ro .. I have raid this application and certify that the intammnaimn provided herein is true,complete and P791- 'Authorized county,and state. otfit eats tut gmitod right of entty.to conduct necery ssa inspectionsto determine mpliance witliyappllcable laws and tolls ,1 understand that I am;solely responsible far the'propet identification ant Labeling of all property;lvms and comers and'making the site a iccssible so that a canplete site evaluation can be perfeintcd; 5r13ttatiircofOwt3e or'Ag ` ®/i bate V23I1(p' Prmted`Niunc of Owaer .or eat 1j1(�•h VaautO Catawba County Environmental Health ( i i ISA t •L3k6 716. .J.C7 r . OP- , 0 eli 0? . Rc• 436 • . , 40 rt.. sip 4 trx4\ 93. - ll Iriti • , , ,.., .; •''' 1.14 , • , --Ay% '' p)o° . 4 , - •1,43 ....1114 4h , r :1 141 % 391)7 JP;' k 1 • * 13 /3•• k . [ 1p r r . , 4 P.' , 1 t ..;,..,),ti . .. 4.5 , 44 ri • ir 81 • .4 r F÷...• 1 , up 11 1- • %IA 'el, i -i r • e ., I I 1 Cao 1.7 1 aft •trc ' 1 / I‘ h i''-'"%■. • i '' * - ) k 1 .1 '+ li hi. II 11"r...,a4-9-krt "---.: • %rni_mmal... ..-- ob -1,:z. . ay d...., -21; ' ' I* , 1 ttY4tt 1 .. it i iiirtil. 1 i TR,% i ;Thre1 1;114 i n t I i It 31 , i i II ,r• "1- -.4 1 , •, 1 1 I r i di • i i / H.-, • ; t ill+ . • I g53)4 . Cr• tit 1"PW■bi- . •. t 1 • 1'14 t " 1 t ' t.„ -'11 irt ■ : , I 1 i oimi/....4 ild t. "ill .tp 4 r,ii J. , :0•11,e. , .- 114111 il pi '. ,A,, ?el ;/ it tirt:4 , it110,4 r IA -* I I %Ft 1 i a. LtIt jou • • I I, I .111 V rin,. . s ji. 1111." 111 NV 1 0111" 'li • - ''' ifill i i oil ' ig It i' 1 .-.1. , ivt iii 1 1 im L i - 141: ,I Pft 1 1 . i 11, I i IL; 1 i 41-1 1 r i-nr s4... ' I Parcel: 460715636672;3971 CHEVLOT HILLS llats Oft RD'SHERRILLS FORD;,28073 Pia ratWopor:product*Ns praparod trom the Catawba County,NO Goccpstlal Inrormadch Screws. Catawba Country Mn mode aubstantlat Oohs co ensure the aocuraoy or location and labatng intswallon consaInced on Thu s map or data on Mb wort.Catawba County promote;And warrununcts W hdopandcn1vorlacabon of any data oarttamed on thh rrwerepcut thoduct by tr.user 7lio Garrey of Catawba,as tarploYarla.apents,•and pantcmel.WW1;and shad not be held Rabe for any and all 6arndpes:Ian or ilatlIty.arh alba, tact:Inaba at oanutoucntlal ctochailacts or may 1 ' ' ' • {, LCapyright2014 Calawba County NC , - - i 051231201e Catawba County Environmental Health AS . 37.16 I " ;'fiN, 1Ir IIL°II{ gi("—"'JLiCC: $g. 111 V cy� 40t 6, 1110 7 SS3S ® •b0 .y-° .4411111441r Ok ISIPP • 52.67 I0 i X41411 lly�l .. igl l ttii� ll i �1 ,ID h ir 1x11I �f !> 1I `N11, ,; 14111 , 4w ' I 41,"111U6 " d1 y 1,,i Ii� 1, *ill 4 �1 I1 IlOpppll;; es �� , .p Il 111 IVDG i ,a�l� 1 1, ilk ao 40 ..r '1 i�1 th( I� ��� (111 l Flo to 4111y , ��{�� dill I lyimikot �I"'`I���yk r 1 ol. 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' �llito�1 �i,..•,i.t,�;.�� �i,i i 1 IJitit,,gro �tti;ii 1 ;li r,i,i,p 1 1111 i 11ilti`liiii- 1d-,I!1�L1 Dui l oIl 1 ,4, grin , ,M Il>I Ili, 1,LIB rr !1✓�hi >tN li tilt I� it I �1i11a � ,rte + [� , r r q 1' 1 111 tiH.�1 � 11 1 I, 1 ( 1 t A I I:../ 1011l 1 i.t II 11 r ,1 ll 1,Itu p�1�Jr ,� ll� ,� 1 i Ih�l 1fih 1 1'h 1 Ilr- - a�>l�'` IIII I ICI � >IIII I� , �I � �i} l Six t I�r1� if tt::ir W[1..owi , .) ,, to o7 , a1 I t1.� rl I 1 p 1 �1`tj;"�'u' " ;4 pllbb4hill!1'p illi Alt r I�I 'IN I�f11 ih1 i�im �i Jt 1'l yllc lii f ,) 11' . 1 1 1 11 j .1-t 'h,' I,i1. ,� I � 1, d �I� et-1111 I . I r ti stilt j7,16 111111'. ii: 1-1-17-:;� ll IA .1! 1 If �0 l ''l 11 i,I I,1 1�! 1�1!lilil,ll I .,�1� ,. r�� �l t,,l• Parcel: 460715636672, 3971 CHEVLOT HILLS 1 in=50ft RD 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 05/24/2016 Parcel Report Page 1 of 1 Parcel Report - Catawba County NC Parcel Information: Owner Information: Parcel ID: 460715636672 Owner: ROUNDS SEAN S Parcel Address: 3971 CHEVLOT HILLS RD Owner2: ROUNDS MICHELLE W City: SHERRILLS FORD, 28673 Address: 3971 CHEVLOT HILLS RD LRK(REID): 12862 Address2: null Deed Book/Page: 2665/1661 City: SHERRILLS FORD Subdivision: CRESCENT LAND AND TIMBER State/Zip: NC 28673-9335 Lots/Block: 110/ null Last Sale: $367,000 on 2005-05-27 School Information: Plat Book/Page: 15/185 School District: COUNTY Legal: LOT 110 SEC 32 L110 PL15-185 PL 15- Elementary School: SHERRILLS FORD Middle School: MILL CREEK 185 Calculated Acreage: .680 High School: BANDYS Tax Map: 012 X 32110 School Map Township: MOUNTAIN CREEK State Road #: 1986 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: $344,800 Zoning2: null Land Value: $146,900 Zoning3: null Assessed Total Value: $491,700 Zoning Overlay: CRC-O,WP-O,FPM-O Year Built/Remodeled: 1996/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 #: 3710460700J Building Details 2010 Census Block: 3010 WaterShed: WS-IV Critical Area 2010 Census Tract: 011504 Voter Precinct: P31 Agricultural District: Parcel Report Data Descriptions List all Owners Deed History Report Assessment Report This map/repod 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=460715636672&typ=P 5/24/2016 /�",:;o., CATAWBA COUNTY Case# WLS2007-00979 _ , /C,- - ' \ Public Health Department ' 't \ Subdivision . --.�. Environmental Health Division CRESENT LAND&TIMBER \� �;1`:I/ PD Box 389, 100-A Southwest Blvd,Newton,NC 28658 SecUBUPh/Lot H 110 (828)465-8270 FAX(828)465-8276 TDD(828)465-8200 PIN# 460715636672 Applicant/Owner SEAN ROUNDS Site Address: 3971 CHEVLOT HILLS RD SHERRILLS FORD NC Property Si SF .68 ACRES Directions: WEST ON HWY 150/RT ON CHEVLOT HILLS RD ® Improvement Permit 0 Authorization To Construct Q Well Permit SITE PLAN ( CS p c _) 1,0 Scale System components represent approximate contours only. The contractor must flag the system prior to beginning the installation to ensure that proper grade is maintained. Do not install system under wet conditions. This permit is subject of revocation if the site plan or site conditions are altered. Authorized State Agent Date Form C rATidemarAVForm Mrubnu.m, cic i'. OPERATION PERMIT rorurticeuseomv �7 , r,. Catawba County Public Health Department `COP File Number 3 a 4 5 a i l 1 t f /. Environmental Health Division WLS2009-00332 r '" .© P.O Box 389, 100-A Southwest Blvd S County ID Number: \ �/ Newton NC 28658 Evaluated For: REPAIR �K4 w Phone: (828)-465-8270 Fax: (828)465-8276 T �� \ownship: Of_li -o9-a is-7 y Applicant: \ 7 ropertyowner: SEAN ROUNDS Address: Address: 3971 CHEVLOT HILLS RD Cay: Cay: SHERRILLS FORD 1 State/Zip: State/Zip: NC 28673-933 \ Phone#: / \ Phone#: / Property Location & Site Information / Address/Road #: Subdrvislon: CRESCENT LAND AND Phase: Lot: 110 3971 CHEVLOT HILLS RD SHERRILLS NC Directions Structure SINGLE FAMILY rec WEST ON HWY 150/ RT ON CHEVLOT HILLS RD/ *original house had 2 #of Bedrooms: 3 bedrooms / adding 1 bedroom for a total of 3 in it of People: house 'Water Supply: NEW WELL P Issued by. 22x6-Megen McBride Classification/Description: TYPE 111 G.OTHER NON-CONY.TRENCH SYSTEMS 'CA issued by: 2246-Megen McBride Design Flow: 3 6 0 'Distribution Type: GRAVITY Soil Application Rate: 0 3 'Pre-Treatment: N/A Drain field - ∎06.4 Wt5 AAA•& 4 -4W exi sickle(N Nitrification Field 3 0 0 Sq. fl. 'System Type: BIODIFFUSER ARC 36 J No. Drain Lines a Installer. Larry Henkle Total Trench Length: 1 0 0 ft. Certification#: 1092 Trench Spacing: — 9 Qlnches O.C. Feet O.C. 'EH S: 2246-Megen McBride Trench Width: Inches 3 Feet Date: 1 0 / a 6 / a 0 0 9 Aggregate Depth: inches Minimum Trench Depth: Inches Minimum Soil Cover Inches Approval Status Maximum Trench Depth: riches Approved❑ Disapproved Maximum Soil Cover Inches uur roe rvumoer "'""- (sourly iu Numner Septic Tank -Ex S tk Manufacturer. Lat. • Long': STB: • Installer: Gallons: Date: / Certification#: 'EHS: 'Filter Brand: ST Marker: ❑ Yes ❑ No Date: / / Reinforced Tank: ❑ Yes ❑ No Approval Status 1 Piece Tank: ❑ Yes ❑ No ❑ Approved ❑ Disapproved y L Pump Tank Manufacture[ Installer l PT: Certification#: Gallons: 'EHS: Date: / / Date: I / Riser Sealed ❑ Yes ❑ No RiserHeght: ❑ Yes ❑ No (Min.6in.) r Approval Status R einforced Tank: ❑ Yes ❑ No ❑ Approved❑ Disapproved t Piece Tank: ❑ Yes ❑ No Supply Line \ rPipe Size: inch diameter Installer: Pipe Length: feet Certification#. `Schedule: "EHS' Pressure Rated ❑ Yes ❑ No Dale: I / Approved fittings ❑ Yes ❑ No Approval Status \ ❑ Approved ❑ Disapproved i Pump Requirement Pump Type: Installer: Dosing Volume: Gal Certification#: Draw Down: Inches 'El-IS: 'Chain: / / Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check-valve ❑ Yes ❑ No Approval Status ■ PVC Unions ❑ Yes ❑ No ❑ Approved ❑ Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ Yes ❑ No COP File Number 3t4ro4 County ID Number • Electric Equipment \\ NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer: Box 12 inches Above Grade ❑ Yes ❑ No Certification #: Box Adj.To Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No 'EHS: Pump Manually Operable ❑ Yes ❑ No 'Activation Method: Date: Approval Status Alarm Audible ❑ Yes ❑ No Alarm Visible ❑ Yes ❑ No ` ❑ Approved❑ Disap;proved. J / 2246-Megen McBride / 'Operation Permit completedr1,by: rtkG -o- Authorized State Agent IY1 I�T Date of Issue: 1 0 / 30 / a 0 0 9 This system has been installed in compliance wth applicable NC General Statutes:Article 11, Chapter 130A, Rules for Sewage Treatment and Disposal, 15A NCAC 18A .1900 et. Seq., and all conditions of the Improvement Permit and Construction Authorization. This property is served by a T'PE 111 G.t rq sewage septic system. Rule .1961 requires that a Type TYPE 111 G. t �p� septic system meet the following criteria: Minimum System Review ByThe Local Health Department: N/A Management Entity: OWNER Minimum System Inspection/Maintenance Frequency By Certified Operator: N/A Reporting Frequency By Certified Operator: N/A Rule .1961 requires that a Type IV and V septic systems designed for a home/business owner must maintain a valid contract with a public management entity wth a certified operator or a private certified operator for the life of the septic system. Rule .1961 requires that Type VI septic systems designed fora home/business owner must maintain a valid contract with a public management entity with a certified operator for the life of the septic system. Rule. 1961 (2)(e)requires a contract shall be executed between the system owner and a management entity prior to the issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the system owner and certified operator are the same. The contract shall require specific requirements for maintenance and operation, responsibiities of the owner and systems operator, provisions that the contract shall be in effect for as long as the system is in use, and other requirements for the continued proper performance of the system. It shall also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. ®Hand Drawing 0 Import Drawing **Site Plan/Drawing attached.** Total Time:(HH:MM) 0 0 Hours 0 0 Minutes 32452 WLS2009•00332 CD.P File Number: County File Number: Drawing Type: Operational Permit Date: 1 0 I 3 0 I a 0 0 9 QInch Scale: °Back = ft. Drawing *N/A S15-1c►n, ih5-kai1Cd aka i vvsrc4ycl io fr /aoo . CVeJ ion 1;115 Re`. A 1 4BIin �� & 0 ,� Well ( reN+auSe �'%c1 K ,\ c �oca�< S� ` Sr . i d *\ ;on �aSAcev. wps v ( I Ij Otbaekdora. xis-1+N` 3(10„ so' 3� IITP�c ���� sot 1*C�ioy\ Sbdwr er,�� 1 (�5o% /iNtYt (5 Apr�ro?� 1 1.7?3/4‘ Qrc rra4. " '5101 1/4196� S M« 135' lAKe- 1E °kw4 1011 5oaaCt wo4ev ( owv.sçoc1■ ,� lios, ekc..) @twat -torn se 1C 6153/4r , CONSTRUCTION fray ' For Office Use Only ;.". \i"-:\--,-r : AUTHORIZATION 'CDP File Number 3 a 4 5 ,_ } 7-+ f-f f. Catawba Count y Public Health Department County lD Number: WL52oos-00332 r ----- -' ,— Environmental Health Division Evaluated For: REPAIR : ` r a, 1 P.O Box 389, 100-A Southwest Blvd PERMIT VALID UNTIL: l.-. (,u_t Newton NC 28658 0 6 / 1 3 / D 0 1 4 Phone: (828)-465-8270 Fax: (828)465-8276 iApplicant: (ICroperty Owner: SEAN ROUNDS Address: Address: 3971 CHEVLOT HILLS RD City: City: SHERRILLS FORD State/Zip: State/Zip: NC 28673-9335 \ Phone#: \ Phone#: / Property Location & Site Information (ACIdressIRoad #: Subdivision: CRESCENT LAND AND Phase: Lot: 110 3971 CHEVLOT HILLS RD °") SHERRILLS FORD NC Directions Structure: SINGLE FAMILY rec WEST ON HWY 150/ RT ON CHEVLOT HILLS RD/ *original house had 2 bedrooms / adding 1 #of Bedrooms: 3 bedroom for a total of 3 in house #of People: \Water Supply: NEW WELL 5 stem S .ecitications Minimum Trench Depth: 1 8 Inches 'Site Classification: PS Minimum Soil Cover: 0 6 Inches Design Flow: 1 ) 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 3 Maximum Soil Cover: a 4 Inches 'System Classification/Description: 'Distribution Type: GRAVITY TYPE III G.OTHER NON-CONY.TRENCH SYSTEMS Septic Tank: Gallons `Proposed System: 25%REDUCTION 1-Piece: QYes 0 N Nitrification Field Pump Required: QYes 0 N QMay Be Required 3 0 © Sq, ft. Pump Tank: Gallons No. Drain Lines a 1-Piece: QYes ONo Total Trench Length: 1 0 0 ft. GPM--vs-- ft. TDH Trench Spacing: 9 Inches O.C. Feet O.C. Dosing Volume: _ Gallons Trench Width: 3 ()Inches — ®Feet Aggregate Depth: nches Grease Trap: Gallons Pre-Treatment: O NSF OTS-I OTS-II . Septic Tank Installer Grade Level Required: 0 OII 0111 OIV Page 1 of 3 WLS 2009-00332 COP File Number 32452 County ID Number: • • • ❑ Open Pump System Shee Repair S stem Required:OYeS O No ONo, but has Available Ssace Repair System Trench Spacing: 3Inches O.C. *Site Classification: PS — OFeet O.C. Trench Width: Inches Design Flow: 3 6 0 0 Feet Aggregate Depth: Soil Application Rate: © 3 inches Minimum Trench Depth: *System Classification/Description: Inches TYPE VA.SAND FILTER PRETREATMENT Minimum Soil Cover: Inches Maximum Trench Depth: Inches *Proposed System: 50%REDUCTION Maximum Soil Cover: Nitrification Field Inches Sq. ft. No. Drain Lines "Distribution Type: \Total Trench Length: Pump Required: Yes No Q May Be Required / ft. Pre-Treatment: O NSF ®TS-I OTS-II Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. Permit Conditions The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit holder • is responsible for checking with appropriate governing bodies in meeting their requirements. 'This permit is to install additional drainlield(to existing system)to compensate for an addition in bedrooms(going from 2 to 3). 'Install new draintields on contour. 'Do not drive,grade,cut,or till over septic area. 'After the installation of This additional drainlield,any septic repair will require a pretreatment septic system. This will require the services of a licensed engineer and a cedifed operator. Additional requirements to be determined at that time. This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit,not to exceed five years,and may be issued at the same time the Improvement Permit issued(NCGS 130A-336(b)).If the installation has not been completed during the period of validity of the Construction Permit,the information submitted in the application for a permit or Construction Authorization is found to have been incorrect, falsified or changed, or the site is altered,the permit or Construction Authorization shall become invalid, and may be suspended or revoked (.1937(g)). The person owning or controlling the system shall be responsible for assuring compliance with the laws,rules, and permit conditions regarding system location, installation, operation,maintenance, monitoring,reporting and repair (1938(b)). Applicant/Legal Reps. Signature Required? OYes ONo Applicant/Legal Reps. Signature' - _ Date: v" / = / 09 'Issued By: 2246-Megen McBride Date of Issue: 0 6 / 1 7 / a 0 0 9 - Authorized State Agent: � � AA i Malfunction Log OYes O Hand Drawing ®Import Drawing Total Time:(HH:MM) **Site Plan/Drawing attached.** Page 2 of 3 0_ Hours 0 0 Minutes COP Fil,e.Numb,er: 32452 County File Number: WLS2009-00332 Drawing Type: Construction Authorization Date: 0 6 / 1 7 / 2 0 0 9 Click below toimport an image from an external location: 4E-1; comocf52i1c- r0 ��)1 30j�roO i;.., cI(f�,f�iion, Coolr:jfrci 2 lo 3 !/rootr;s- On acdrhoria I /00 1?.•• C�1 ZS 7C f e c"� boil JA'J,T1- Gt added" , *New ato ,';eici, l'nus� Di: cr 10561-% - 50-A. -6ro0, IaYCc - 5. 44. frupl S5rUC7ku(eSo 15-fa. -from bo;BmeH cu�( (4 cc/472-r-i.) — go % -from \NC'uS /6 -0 -(;om 9fdp;rf' tiles, - -- n I _t.._ vlelV r1 • AreO, a z K I. _ I� �0d52 1�F- i- ` Ica J� 7cco'ne HExisHia- *l1 7o Be. AEanclanej, 3 E¢drm7d I This vied mos} be. -(,fat 19x40 —� abartlonecl prior -t-o AdClilion 1 dvaIn-(•field nu-Iallml Ion . Approx.Areq Qv' r5'ri� 6FEx;siin� aai. loop ■ °_'_, S15 em .1// n I Fi>}ure SeLAic Re '.r I �S. �pFa.ln`ef Y_- 0.94, 51.1£, Page 3 of 3 \WA.N Case# WLS2009-00332 — ,\ CATAWBA COUNTY Subdivision Crescent Land and Timber .� I GI Public Health Department e /�� Section/BI/Ph/Lot# Lot 110 <-, 't io, . Environmental Health Division 4607-15-63-6672 yP"� ' PO Box 339, 100A Southwest Blvd,Newton NC 28658 1 IN# c5'4'Z yw (828)465-8270 Fax (828)465-8276 'I'DD(825)465-8200 +\1^\IJ , Applicant/Owner Sean Rounds Site Address: 3971 Cheviot Hills Rd. Sherrills Ford,NC Property Size: 0.68 acres Directions: WELL PERMIT Proposed use: Private ® Public ❑ Semi-Public ❑ Other GROUTING DEPTH: MINIMUM 20 FEET SETBACKS: I. BUILDING FOUNDATIONS 25 FI', 5. UNDERGROUND STORAGE TANKS 100 FT. 2. EXISTING&PROPOSED SEPTIC SYSTEMS MIN. 50 Fr. 6. STREAMS/BROOKS/CREEKS 50 FT. 3. EXISTING&PROPOSED SEPTIC REPAIR AREA MIN. 50 FT. 7. LAKES/PONDS RESERVOIRS 50 FT 4. SEWAGE PUMP SUPPLY LINE 50 FT. ALL OTHER POSSIBLE SOURCES OF GROUND WATER CONTAMINATION 100 FT. The well driller must verily all separations are adhered In before drilling the well. If the well driller is unable to maintain any of the above separations,contact the Health Department at(828)465-8270 before drilling the well. SEAi IIT'I'E PEA FOR 'ERM (I TED WELL LOCATION LL !.I.'l ilia .i ( 17 2-D6' 1550-D BY ' PERMIT SST. NC'DATE / 2 _ d a CUSTOMrjfrGNATURE VrE / WELL INSPECTION: GROUTED DEPTH: 20' / ❑ DATE: 7- IS"0 q I INITIALS: PINY\ APPROVED CASING: PVC i STEEL ❑ DATE: 7-15-09 INITIALS: Min CASING HEIGHT 12' ABOVE LAND SURFACE Elf DATE: 7-22-09 INITIALS: PAM WELL COMPLETION REPORT RECEIVED ❑ DATE: INITIALS: WELL HEAD APPROVED 1/ M DATE: ¢7-22-09 INITIALS: SIAM WATER S.AMLES TAKEN: BAT/ 10 g✓ N/N DATE: O'1I-0 ( INITIALS: kit 131 \Nl. LeinCOk Neil ,,,i,',3 „rifyi., WE LDRILLER J DATE.DRILLS Well permits are valid for 5 years from the date of issuance and are subject to suspension and/or revocation for non-compliance with appropriate state and local rules and regulations,or if false information was given in order to obtain a permit. Wells shall be constructed in accordance with all state and local regulations and rules. The Well Completion Report must be submitted to the Health Department within 30 days upon completion of a well. CERTIFICATE OF COMPLETION AUTHORIZED STATE AGENT APPROVAL DATE -- CATAWBA COUNTY (CLEW- Case# WLS2009-00332 Z „It 'G Public'Health Department i Subdivision Crescent Land & Timber `.n., Environmental Health Division / ; ' PO Box 389, 100A Southwest Blvd,Newton NC Section/BI/Ph/Lot# Lot 110 °.842 ,>, (828)465-8270 Fax (828)405-8276 TDD(828)465-8200 PIN# 4607-15-63-6672 WELL p-a9-aXSb Applicant/Owner Sean Rounds Site Address: 3971 Cheviot Hills Rd. Sherrills Ford, NC Property Size: 0.68 acres Directions: WELL ABANDONMENT PERMIT • WELL TYPE: DRILLED, BORED, DUG, ETC drilled r---P e H7) 2o1 ISSUED _ PERMIT IS .UAN E DATE se / . 2 — 0 OWN VIR LEGAL REPRESENTATIVE DAT'. WELL ABANDONMENT INSPECTION TOP 3' OF CASING MATERIAL REMOVED(BORED WELLS) YES NO WELL DISINFECTED: DATE ...../-2.2.-09 INITIALS /Ki WELL FILLED WITH APPROVED MATERIAL (BORED OR DUG WELL ONLY) DATE INITIALS WELL GROUTED TO SURFACE(DRILLED WELLS ONLY DATE 7-2.2117 INITIALS NMI. WELL CAPPED WITH CONCRETE DATE 7-ZZ-67 INITIALS Mvin1 WELL ABANDONMENT REPORT RECEIVED DATE INITIALS PERSON ABANDONING WELL OWNER .1 DATE p CONTRACTOR MIA Lik(dlh Well DI'illiv� DATE 7-22 0 Wells shall be abandoned in accordance with all state and local regulations and rules. The Well Abandonment Report must be submitted to the Health Department within 30 days upon completion of a well. AUTHORIZED STATE AGENT COMPLETION DATE \Documents and Settings\rnmcbride\Desktop\OPs,memos, CDP draw ings\wls2009-00332_wellabandon.docx tiA CATAWBA COUNTY Case# WLS2009-00332 i�� Pubic Health Department Subdivision Crescent Land and Timber tit 1 Environmental Health Division Section/Ell/Ph/Lot# Lot 110 Sri: ,,t 1 PO Box 389, 100A Southwest Blvd,Newton NC 28658 PIN# 4607-15-63-6672 CA,47 (828)465-8270 Fax (828)465-8276 TDD(828)465-8200 \84%9' Applicant/Owner Sean Rounds Site Address: 3971 Cheviot Hills Rd. Sherrills Ford,NC Property Size: 0.68 acres Directions:. Improvement Permit ❑ Authorization to Construct ❑ Well Penn it El SITE PLAN 1< Ne\PI NielI must Le_ crl I.eas-�e .1\ Ra. `55'-5 sm'd ZJ�• Torn Ant alruclw� ���lo� N/ - - roc YIJ IinaS NO 5 41- -From P ��rn - 50 -cI, corn iffAic, Sts ems cs„.:—(i. X Keep well 04 uP jtower line- `a rikis of way, • �M �J ( — �p°52' �E — --- axisiit, V\fdi To Qe AIDandaned. tQ�o, 1'obecvme- This will m04 be. . 3 �ec�r�fi5 )r�x yo abcmcioned pr i.er -I o crdd�fi Na - T��a> Adc1i-lioh _ Arailt-fielcf irlsialta\jon . of Exls-liac� — — SePlicSis4em , - _ o5 51.1Z' System components represent approximate contours only. The contractor must flag the system prior to beginning the installation to ensure that proper grade is maintained.Uo not install syste t under Net con Mons. This permit is subject to revocation if the site plan or site conditions arc altered. AUTHORIZED. ATE AGENT DATE ` . NCDENR. Division of.Environmental Health On-Site Vastewater Section Tate: 0 6 / 1 s / 7 0 0 9 Soil/Site Evaluation *File#: 3 a 4 5 a For On-Site Wastewater System PIN #: WLS2009-00332 *Owner SEAN ROUNDS Proposed Facility SINGLE FAMILY Proposed Design Flow(.1949) 3 6 0 Location of Site 3971 CHEVLOT HILLS RD Property Size 0.68 Water Supply EXISTING WELL Evaluation Method Auger .1940 Horizon SOIL MORPHOLOGY Landscape Depth .1941 Other Profile Profile# Slope % (IN) Texture Structure Consistence Color Color Factors POS 1 L 0-27 CL 2-Modr sbk fr ss sp 1942 Wet ok 27.35 2-Mod' sbk fr ss sp 1943 Depth 4 0 ps CL*SAP GPS Saprolite (in) 35-40 1-Wee abk fi ss sp .19441 Rest. e� SAP L;,l. 1947 Class ps t� EHS Profile Megen McBrip LTAR 0 • 3 .1942 Wet % i 1943 Depth GPS Saprolite(in) 1944 Rest. Horizon Iri .1947 Class �- EHS Coptilrofile Profile 1 LTAR— ' .1942 Wet. % 1943 Depth GPS Saprolite(in) .1944 Rest Horizon {'% 1947 Class EHS Coptriofile Profile LTAR • 1942 Wet % 1943 Depth • GPS Saprolite:(in) .1944 Rest Horizon .1947 Class EHS Coptrofile Profile LTAR_ • 1942 Wet % 1943 Depth GPS Saprolite(in) 1944 Rest ,.,� Horizon faA 1947 Class �A EHS Cop�rotile Profile I I LTAR ' Available Space (.1945) PS Other Factors(.1946) PS Site Classification (.1948)Ps Initial LTAR: 0 . 3 Repair LTAR: 0 . 3 Others Present: Comments: House is currently 2 bedrooms...addition will add 1 bedroom. Will be 3 total. Need to add 1 bedroom's worth of additional drainlield. Evaluated By: Megen McBride Attach Image The "Open Drawing Form" button, opens the the drawing form. The "Import" button, attaches the drawing, or other image into the space below. DANIA \t 115 j Open Drawing Form I VI T5,,,0, ,a\iSci, 0 6 c 'Nutt'o n S o lake SMoa Profile: 1 Q X • Y Z Profile: Q X • Y Z • Profile: ®' X • Y • Z Profile: Q X • Y Z • Profile: Q X • Y • Z Profile: Q X • Y Z • Profile: Q X • Y Z Profile: Q X • Y Z • Profile: Q X • Y • Z • Profile: Q X • Y Z • A$ A CATAWBA COUNTY �� � IOOA SOUTHWEST BLVD NEWTON, NORTH CAROLINA 28658 INVOICE/RECEIPT p„c*ie�►e'S PHONE: 828.465.8399 U Ink" C Tuesday, May 24, 2016 1$t�2 sm www.catawbacountync.gov Invoice Number: 05-16-328653 Invoice Date: 05/24/2016 EHPR-05-2016-23937 CASE TYPE: Environmental Health Plan Review WORK CLASS: OSWP SITE ADDRESS: 3971 CHEVLOT HILLS RD, SHERRILLS FORD NC 28673 Applicant LAKE VISION DEVELOPMENT, 2242 LONGCOVE CT, SHERRILLS FORD NC 28673 JODI@LAKEVISIONDEVELOPMENT.COM LAKEVISIONDEVELOPMENT.COM Contact Person LAKE VISION DEVELOPMENT,2242 LONGCOVE CT, SHERRILLS FORD NC 28673 C:7048809118 Owner SEAN & MICHELLE ROUNDS, 3971 CHEVLOT HILLS RD, SHERRILLS FORD NC 28673 C:7042580307 Contractor *LAKE VISION DEVELOPMENT INC, 2242 LONGCOVE CT, SHERRILLS FORD NC 28673 8:7045060807C:7045060807F:8289940919 PHILaLAKEVISIONDEVELOPMENT.COM ACCOUNT: 5000122 PAYOR: *LAKE VISION DEVELOPMENT INC FEES EHPR-05-2016-23937 FEE AMT DUE AMT Authorization to Construct Fee(New/Expansion) 05/24/2016 5300.00 $300.00 Fee �.I1s rfirrig III i 1 v '^°ITd II I t �' 1 '� tip " 1 t I Y� III' I'� � _ 2 �„„ � �{L� ,(Improvement Perm}fl,Fee ,J,GA(�����Illl�lllp�'u1�7!�I��I�����IL�II���������11��0�/_4/2016p 1a �p�u,w$'I50,00.,. C11IIINiuu,.:, .. 5150,.00.,, FEES: $450.00 $450.00 TOTAL FEES : $450.00 $450.00 invoicereceipt 05/24/2016 10:14 Page 1 of I