HomeMy WebLinkAboutEHPR-10-09-2139 (2).TIF
THIS IS NOT A PERMIT WLS # ~MK464 0139
CATAWBA COUNTY HEALTH DEPARTMENT
Application for Environme al Services
IP AC S. T. Rpr. S. T. Exp. Exist. S. T. Well Prmt. Replacement Well
1. Name to Appear on Permit W'w'..,., S,nJL
2. Permit Requested By Business Phone $a$-~V`~-SIoaO
Address `Raa Ca-- e'yg_ eA Nttir4e-- RC_ aeepsg Home Phone 908- IUNS_' Uls
3. Property Owner i~ S,p.e- Business Phone
Address t(k3;) $ Home Phone Sat - 4 a$- $a$ a
4. Name of Subdivision we- Lot # Section/Block/Phase
Property Address
Directions to Property _ t( ~1 L(S urCh y'.'40 C1hei d
'
Y19
I 1 i t~s
I> t
5. Property Size: Square Feet Acres 01.7"19 a. Date Platted/Recorded
6. TYPE OF FACILITY: House X Mobile Home Dimension of Structure _ Bedrooms*_
*Any. room that will be intended for sleeping at the time of construction oi• 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 system size increase, in the future.
Basement: 0/110 Water Using Fixtures in Basement:G~no No. in Family
Whirlpool Tub ye Ps Gallon Capacity ,
MULTIPLE FAMILY RESIDENCES: Um Total Number of Bedrooms
DAY CARE: Number of Children
RESTAURANT: Seats Square Feet Dining Area -Square Feet Food stand/Meat Market Floor Space
TYPE OF BUSINESS: Number of Employees 1 st 2nd 3rd
OTHER: (Specify)
7. Do you anticipate any additions to Facility? Yes _ o
If so, describe:
8. Has any grading, removal, or addition of soil been done to this property? Yes /9)
If so, describe: 1
9. Are there easements/right-of-ways recorded on this property? Yes o,
10. Is a public water supply available on or adjacent to the above property? Ye / No
Check type that is available: [ ] Community well [ ] Semi-public well [ ] County/City/Township water line
**If No, a Well Permit must be issued with the Septic Permit.**
11. Well Type Applying For: [ ] Individual well [ ] Community well [ ] Semi-Public well [ ] Irrigation well
[ ] Geothermal well
12. Monitoring Well Request? Yes/ No # of wells Name of Site
I understand that this is a formal application for a well permit, Improvement Permit or Authorization to Construct a ground absorption sewage
disposal system to serve the above described facility on this property and authorize Catawba County Health Department employees to go on
this property for evaluation purposes. I certify the above information to be correct and understand that an Improvement Permit issued as a
result of this information is transferable and may be eligible for a non-expiring date, but may be revoked if this information, site plans or
intended use changes for the proposed facility. A Well Permit and Authorization to Construct issued by this department is valid for (5) five
years from the date issued and is not transferable.
Note: You must obtain Zoning Approval prior to locating a home or structure on this property. Any representation by you of house or structure
location should conform to applicable setbacks.
**IF A PERMIT HAS TO BE REDESIGNED AND/OR RETRIPS MADE TO THE PROPERTY, THERE IS AN ADDITIONAL CHARGE."
Date kA 6\pq Signature of Owner or Agent
I
A Cp CATAWBA COUNTY, NC
100-A South West Blvd PLAN RECEIPT
Newton, NC 28658-
V (828)465-8399 Thursday, October 15, 2009
184 'Z sM www.catawbacountync.gov
Plan Case: EHPR-10-09-2139 Invoice Number: INV-10-09-256260
Environmental Health Plan Review Invoice Date: 10/15/2009
Fee Name Fee Amount
Existing Tank Check Fee Fixed $80.00
Total Fees Due: $80.00
PAYMENTS
Date Pay Type Check Number Amount Paid Change
10/15/2009 Check 4014 $80.00 $0.00
Total Paid: $80.00
Total Due: $0.00
plan receipt;66f9cfl5-f210-4f95-b70c-5569bd2293b9;.rpt 10/15/2009 08:33