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HomeMy WebLinkAboutEHPR-06-2016-24182 (2).TIF CO THIS IS NOT A PERMIT Case # EI-IPR-06-2016-24182 CS" a CATAWBA COUNTY HEALTH DEPARTMENT 0 �. t 0 !' PLAN REVIEW APPLICATION FOR ENVIRONMENTAL SERVICES .I C i It 1842 s^M Environmental Health Plan Review - OSWP r'a Es a r : REPLACE_WELL 0 { o1e • Owner DAVID COX, 2791 DAVID COX RD, MAIDEN NC 28650 H:8284289715 C:7046340218 HOME:8284289715 NAME TO APPEAR ON PERMIT David Cox SITE ADDRESS: 2791 DAVID COX RD, MAIDEN NC 28650 PIN # 365604738470 NAME of SUBDIVISION: Lot ft Section/Block PROPERTY SIZE: Square Feet 1,278,921.60 Acres 29.36 DIRECTIONS: Hwy 321 from Maiden, Left at Food Lion, Left onto Buffalo Shoals Rd, Right onto David Cox Rd, 3rd house on the Right w/Pond in the back. PRIMARY CONTACT: Owner SEWER TYPE: Septic Tank GALLONS PER DAY: 360 WATER SUPPLY: Private Well DESCRIBE WORK: Replacement Well. Current well is working & has filtration system to remove minerals and water is still not good. Owner has proposed a new well location. 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, Several out Bldgs EXISTING STRUCTURES ON SITE (IF ANY) DIM EXISTING STRUCTURE: 84x76 NUMBER OF EXISTING BEDROOMS: 3 #OF OCCUPANTS: 2 PROPOSED CONSTRUCTION BASEMENT? No BASEMENT FIXTURES? No 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 F9-chapplication 06/28/2016 10:45 Page 1 of 4 CATAWBA COUNTY Case// EHPR-06-2016-24182 .T tli ft Public Health Department Subdivision As s) Environmental Health Division PINR 0 It . 365604738470 PO Box 389. 100-A Southwest Blvd.Newton.NC 28658 /842 s. NAME ON PERMIT: (DAVID COX),2791 DAVID COX RD, MAIDEN NC 28650 ( David Cox) Site Address: 2791 DAVID COX RD, MAIDEN NC 28650 Property Size: S q uare Feet 1,278,921.60 Acres Directions: Hwy 321 from Maiden, Left at Food Lion, Left onto Buffalo Shoals Rd, Right onto David Cox Rd, 3rd house on the Right w/Pond in the back. 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 omplete site evaluation can be performed. Date: G — 2 y— / L Signature of Applicant or Agent as, 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 .111^II lll^'�—�i II SI hT�I 'l 1li17 i ii 11 1r6i Jt T - ( i i r t "" i i h - i�itl 'FEENAMEiitt' wpa. nig11,d imFEErA MOUa N^rnT I Well Permit & Inspection Fee 06/28/2016 $300.00 pt1�I1ti lf TOTnL FE 'P.$300 00 ,.I.i1.11.1iu-..I�__t 1➢1�.t.�. s^!s .11 � .-11_._.._ .,!.1L„1111hu!L_�.,�.Ltd L.1„L__.u:, _1i�' 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-ehapplicaliion 06/28/2016 10:45 Page 2 of 4 C !I TA\\\ `g'� A THIS IS NOT A PERMIT F. r1 ■.[, I CATAWBA COUNTY HEALTH DEPARTMENT „o Application for Environmental Services Page 1 Improvement Permit ❑ Authorization to Construct❑ Septic Repair n Septic Malfunction❑ Septic Expansion ❑ New Well PermitgReplacement Well ❑ Well Abandonment❑ Well Repair n Existing System Inspection (Pre-Approval Required) ❑ App d Application is for New Construction 1 ' Existing Facility `7/ Property Address 2 / /9v iL cdy` Xfc) Subdivision 4\ _ •A4 4 /d n/ A/e 2 cs'‘Sb Lot# Acres Section/Block/Phase g Property �ir-7 d27C1� i2 — #d ,�J/ A A-f A o vd /- Lx t� 'vi/ Bicf 4 4 Driving Directions to Pr A ,p lJ G GX J NAME TO APPEAR ON PERMIT? [ Owner ❑ Applicant ❑ Contractor Applicant Contact Information Name 17,9-to J r> x Address 2 -2 7/ /)9-z.,pc-/ Kit= x :ed /1�.44JJ-z,v Phone tr,-7 �,� of a 4 97/-j I Cell Phone 70 y G 3 ¢ Z / Owner Contact Information Name , /94k 4,2_ Address Phone I Cell Phone Contractor Contact Information Name Address Phone I Cell Phone WHO WILL BE THE PRIMARY CONTACT? ❑ Owner [ Applicant ❑ Contractor Description of Existing Structures on Site # of Bedrooms k � Structure Dimensions # of Occupants Basement ❑ Yes RNo Basement Fixtures a Yes r-No 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. O Yes Does the site contain any jurisdictional wetlands? e Does the site contain any existing wastewater systems? Q Yes Is any wastewater going to be generated on the site other than domestic sewage? CA Yes lagO Is the site subject to approval by any other public agency? O Yes fl-N(i Are there any easements or right of ways on this property? Describe Existing water supply in use ❑/Individual Well El Community Well ❑ Semi-Public Well n 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 of your preference) ❑ Accepted ❑ Alternative ❑ Conventional ❑ Innovative ❑ Other ❑ Any v` m cATAATI326 CATAWBA COUNTY HEALTH DEPARTMENT Application for Environmental Services Page 2 Proposed Facility Type n Primary Residence n New Residence ❑ Addition to Residence # of New Bedrooms *t Project Description Structure Dimensions # of Occupants Basement Yes ❑ No Basement Fixtures Ci Yes No El Accessory Structure(s) Describe #of New Bedrooms *t if applicable Structure Dimensions # of Occupants Accessory Dwelling ❑ Yes El No Plumbing ❑ Yes ❑ No Describe Plumbing Needed ( Multi-Family Residence#Units #Bedrooms per Unit*t Total# Bedrooms *t Structure Dimensions ❑ 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 ❑ Other Facility Type Specify If Church# of Seats Kitchen [ Yes ❑ No If Daycare Specify Occupancy Application for Well Cons uction/Abandonment/Repair Proposed Well Type ndividual Well n Semi-Public Well E Community Well Abandonment Type Drilled n Bored ❑ Dug Unknown Well Repair Requested ❑ 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 arc 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 P- - Date l% - Z / 6 �,.. Printed Name of Owner or Agent 04u ic-1 „o Catawba County Environmental Health \\\\ l . 1111 DAVI D Cplp\ \ 70 �i-.- pas) .40010°. J0` •. a, P1111414111 —\ 25.00 . Ill ``70 \\-\ �� _ dial /0'o ® ° \ 7070 lib �l * . . 44k ' :2, .141111\ \CRP ` CI )\\\\1 - •V `�11C`9g0 / :,--____.\\ \--......--)\ ch & • 9kr Parcel: 365604738470, 2791 DAVID COX RD 1in=150ft MAIDEN, 28650 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 06/28/2016 Catawba County Environmental Health fr % cl 141/4 g, (------: 77: (24, 15 „-----1 .--/-. .'''''\\.\ \ 9a5 n 5ai �'',/ 2) �_ s m 2§/ 4k zzr2a ....45.100:490X-% ��—, Ao 7 / ..„, ._,___x 0 .,,,,.. - ,� P. hR / f, . '15 1 ' ,P N tc n fr;:i4/ 9O I � I c i ilk�s r. \ . )1 ,....1/4._ C. -;._-.--1- F '1:1- 90-4\ \\---- ?s • \ -7 \ Cfr Parcel: 365604738470, 2791 DAVID COX RD 1in=300ft MAIDEN, 28650 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 06/28/2016 Parcel Report Page 1 of 1 Parcel Report - Catawba County NC Parcel Information: Owner Information: Parcel ID: 365604738470 Owner: COX DAVID EDWARD Parcel Address: 2791 DAVID COX RD Owner2: COX JUDY D City: MAIDEN, 28650 Address: 2791 DAVID COX RD LRK(REID): 201220 Address2: null Deed Book/Page: 2227/1271 City: MAIDEN Subdivision: State/Zip: NC 28650-9645 Lots/Block: / Last Sale: School Information: School District: COUNTY Plat Book/Page: Legal: 2813 DAVID COX RD Elementary School: TUTTLE Middle School: MAIDEN Calculated Acreage: 29.360 Tax Map: null High School: MAIDEN Township: CALDWELL School Map State Road #: null Tax/Value Information: Tax Rates(pdf) Zoning Information: City Tax District: AU in County Zoning District: COUNTY County Fire District: BANDYS Zoning1: R-40 Building(s) Value: $293,900 Zoning2: Land Value: $147,000 Zoning3: Assessed Total Value: $440,900 Zoning Overlay: Year Built/Remodeled: 2000/null Small Area: BALLS CREEK 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 #: 3710365600J Building Details 2010 Census Block: 4013 WaterShed: null 2010 Census Tract: 011600 Voter Precinct: P9 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 arid 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=365604738470&typ=P 6/28/2016 p 3.. oc - 31.0 W d A. i CATAWBA COUNTY HEALTH DEPARTMENT �S° • Telephone: (828)465-8270 TDD: (828)465-8200 WLS #62665�OQ9.0 3 Improvement Permit AC Repair Permit. Operation Permit. System Type Well Permit. Replacement Well_, Owner/Agent &7 O COX Phone Address 017q/ i>4-1//0 COX Rd Subdivision IB Al _ .�„���, � Section/Block/Phase Lot# Lot Size i Directions: G _C • iilZ Yi" e • p7 • 1...i a /7%f//I)' .Dx'repi • 9*J f2T Property Address• 7 ./ - A01/ CO X 7 Facility: House A Mobile Home Business Multi-family Other: Pin Number_ s.-(JY- 'SRI S/ Other . Zoning Approval # k Bedrooms 3 # Seats # Employees . Application Rate GPD Flow_. Hot Tub or Spa yes/no Special Fixtures • Basement yes . 100% Repair Area yes/no Basement Plumbing yes/no Water Supply: Private Well yr Public Semi-Public �J ****i*********************************************************************** ******************************************tom Type of System: Trench Bed Pump Pump/Panel Panel LPP Other (liS Septic Tank Size Pump Tank Size Nitrification Field: Total Square Feet Depth of Stone Bed Size Trench Width Total Length of All Trenches Number of Trenches Trench Length / / / / / Feet on Center Maximum Trench Depth Distance of Nearest Well *DO NOT INSTALL SEPTIC WHEN WET* WELL RECORD REQUIRED AT COMPLETION* *************************************************************************************************************t************* Topo % Slope Texture Structure Clay Min. GO I Soil Wetness " Soil Depth " Avalab Hop.space _" \' // Available lass PS \ Overall Class S PS U Comments: �Q, �� \� `\LA 1\�JJ a Vf 6 ViCg( i alv . ..--Pi Cl Filter Required (7Rt/m co,l' Riser required when tank is more than 6 inches deep. -*NO GUARANTEE OR WARRANTY IS IMPLIED OR GIVEN AS TO THE PERFORMANCE OR LENGTH OF TIME THIS SYSTEM WILL FUNCTION** ********t************t****t******************************************•*****t**************tttt********t t*4**i*****t***** *Improvement Permit has no expiration date and is transferable, but may be revoked if site plans or intended use changes for the proposed facility. An Authorization to Construct is valid for (5) five years from date issued and is not transferable. Well Permit valid for 5 years provided site conditions do not change. Well location, installation, and protection must meet state and local regulations, and must be inspected and approved by a representative of the Catawba County Health Department before any ,onion of the installation is put into use. The siting of the well by the Health Department staff is to provide protection from known toss'- e s:urces of contamination. No volume of water is guaranteed any�st�e b the Health Department. Pe to /L EHS At L;, / __• , 72' Owner/Age t 4, _ _j - Septic Tapk Installed I • Date Well Installed By/4/ SM^-4- Well Grout Approval Date c-c2 --c Well Head Approval Date 4'-a3`o' Date Sample Collected Date of Results Results EHS . et a ' rkal White-Office Yellow-Owner/Agent Pink-Building Inspection Authorization to Construct a'Iq ! Ot,Lu,,c9._ C'ox ; li5-o -O l 3Tb 4 CATAWBA COUNTV HEAL b DEPARTMENT °r -�( Telephone (828) 465-8270 TDD 11141.,i t) 465-82000 E tL✓*'1 N0 8 6 9 8 IP K AC ' \ Rpr Prmt. Opr Prmt. Sys. Type 3+=t" Well Pnnt. eplll�/ace ent Well Well Rpr Prmt. Owner/Agent . I d I ' Phone Address I1 :7) SAui et Ctt X 12-d Subdivision 4 4.t d e.1t.I Section/Block/Phase Lot# Lot Size - el Directions j.(g S 0 E 6,- 4 to S ke'va-La I Cross i-s Ms-i dc^0 _ i) .rl n,cad (ex- 4C1 4 /01- G.-- nk A /' Property Address Oriel] OPcU va COX ad Facility' House X, Mobile Home Business Multi-family Other Pin Number 3(etio-QC)-(,L( -pga,Q Other Zoning Approval # .00 i t a-s-a #Bedrooms `3 # Seats # Employees Application Rate GPD Flow 3 4* Hot Tub or Spa yes/no Special Fixtures Basement yes�i 100% Repair Area e no Basement Plumbing yes/no Water Supply' Private Well D( Public Semi-Public *4******4****i***4***44*4********4*4******4*4*4****************4******4*******4**4****4****44***********4**4444*t*t t******* Type of System. Trench K, Bed Pump Pump/Panel Panel LPP Other 1 Septic Tank Size Pump Tank Size Nitrification Field. Total Square Feet(I),ISO Depth of Stone 1 Z Bed Size Trench Width .-(u Total Length of All Trenches 3 45 Number of Trenches -3 ,t Trench Length X 15/I/�i(( / / / Feet on Center g Maximum Trench Depth d L/ _ Distance of Nearest Well /CO *DO NOT INSTALL SEPTIC WHEN WET* *WELL RECORD REQUIRED AT COMPLETION* **t*********************44***4**4***************************4*t4*4**********4******4**********4444***444*44******4*****4*** p� Topo 61 I) % Slope Texture 1,•. -e I /5 Structure L' Clay Min. R..."- / 03 Soil Wetness O Soil Depth '>`= O Restric Hoz. at ' C] Available space 6e. no 58 Available Class i ' 3 g Vr-' Comments _ _ \_ le e-Z. Vateil ti - \ w&U Is ) I t "r i/I \ „.,00 - J, L ■ • '2' i & Filter Required Riser required when ,o/,,,TS Co/ /L Of tank is more than 6 inches deep. **NO GUARANTEE OR WARRANTY IS IMPLIED OR GIVEN AS TO THE PERFORMANCE OR LENGTH OF TIME THIS SYSTEM WILL FUNCTION** *4*******************************************t***4***************************4****************4****4*4444************t***** *Improvement Permit has no expiration date and is transferable, but may be revoked if site plans or intended use changes for the proposed facility An Authorization to Construct is valid for(5) five years from date issued and is not.transferable. Well Permit valid for 5 years provided site conditions do not change. Well location, installation, and protection must meet state and local regulations, and must be inspected and approved by a representative of the Catawba County Health Department befor portion of the installation is put into use. The siting of the well by the Health Department staff is to provide protection from known e •urces of contamination. No volume of water is guaranteed at any ite by the Health Department. /ii�� Permit Date .t iii EHS z /!t- 1.2.47, OwnertAgent �_^'� Septic Tank Installe � , ft - Datel- - EHS /ip ,i . Well Installed By Well Grout Approval Date Well Head A( prova Date Date Sample Collected Date of Results Results EHS White-Office Blue-Building Inspection Operation Permit Yellow-Owner/Agent Green-Building Inspection Authorization to Construct .1(3A Co CATAWBA COUNTY �^ ;tft 100ASOUTHWESTBLVD �� a NEWTON, NORTH CAROLINA 28658 RECEIPT C.3 va®dve C PHONE: 828.465.8399 es Tuesday, June 28, 2016 I� s.°, 1$42 sm www.catawbacountync.gov PAYOR: Cox, David PAYMENTS TRANSACTION NUMBER: 1RC-708 1 80-28-06-20 1 6 PAYMENT DATE: 06/28/20 16 PAYMENT TYPE: Check 9962 INVOICE NUMBER FEE NAME FEE AMOUNT 06-16-329891 Well Permit& Inspection Fee $300.00 TOTAL PAYMENTS : 5300.00 EHPR-06-20 1 6-24 1 82 CASE TYPE: Environmental Health Plan Review WORK CLASS: OSWP SITE ADDRESS: 2791 DAVID COX RD, MAIDEN NC 28650 Owner DAVID COX, 2791 DAVID COX RD, MAIDEN NC 28650 H:8284289715C:7046340218 ** NO PEOPLESOFT ACCOUNT ASSIGNED ** receipt 06/28/2016 10:44 Page 1 of I