HomeMy WebLinkAboutEHPR-06-2016-24016 (2).TIF ,A �G THIS IS NOT A PERMIT Case # EHPR-06-2016-24016
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Kltn 7 PLAN REVIEW APPLICATION FOR ENVIRONMENTAL SERVICES
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Applicant GEORGE LAIL,2248 OLD SHELBY RD, HICKORY NC 28602
H:828-324-2929 HOME:828-324-2929
NAME TO APPEAR ON PERMIT
George Lail
SITE ADDRESS: 2380 OLD SHELBY RD, HICKORY NC 28602 PIN # 278111764302
NAME of SUBDIVISION: Lot# Section/Block
PROPERTY SIZE: Square Feet 468,705.60 Acres 10.760
DIRECTIONS: Old Shelby Rd 1 mile south of 1-40 exit 121
PRIMARY CONTACT: Applicant SEWER TYPE: Septic Tank
GALLONS PER DAY: 100 WATER SUPPLY: Private Well
DESCRIBE WORK: Replacement well
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? Yes
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: " NO STRUCTURE SELECTED **
FACILITY TYPE: Business OTHER DESCRIPTION:
DESCRIPTION OF brick shop building w/ 1 bathroom & 1 employee, Old house (no septic for house)
EXISTING STRUCTURES
ON SITE (IF ANY)
DIM EXISTING STRUCTURE:
NUMBER OF EXISTING BEDROOMS: #OF OCCUPANTS:
PROPOSED CONSTRUCTION
BASEMENT? No BASEMENT FIXTURES? No PLUMBING REQUIRED?
Desired system types(Improvement Permit or Authorization to Construct):
ACCEPTED: ALTERNATIVE: CONVENTIONAL:
OTHER: INNOVATIVE: ANY:
Other described:
APPLICATION FOR WELL CONSTRUCTION
PROPOSED WELL TYPE: Individual Well REPLACE WELL?: YES
E9-chapplication 06/06/2016 12:42 Page I o14
M\ CATAWBA COUNTY Case# EHPR-06-2016-24016
Public Health Department Subdivision
® , Environmental Health Division PIN# 278111764302
""b PO Box 389. 100-A Southwest Blvd,Newton,NC 28658
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NAME ON PERMIT: (GEORGE LAIL), 2248 OLD SHELBY RD, HICKORY NC 28602
( George Lail)
Site Address: 2380 OLD SHELBY RD, HICKORY NC 28602
Property Size: Square Feet 468,705.60 Acres 10.760
Directions: Old Shelby Rd 1 mile south of 1-40 exit 121
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.
Date: Signature of Applicant or Agent
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
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Well Permit& Inspection Fee 06/02/2016 $300.00
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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)
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