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HomeMy WebLinkAboutRBPR-08-2016-24420.TIF .Y'P' - 4.G THIS IS NOT A PERMIT Case # RBPR-08-2016-24420 4' rftja 4 CATAWBA COUNTY HEALTH DEPARTMENT ❑' . rl• o f❑� 44:i°' PLAN REVIEW APPLICA ION FOR ENVIRONMENTAL SERVICES . 1842 s Residential Building Plan Review - Manufactured Home ,ofr •rEi o IMPROVEMENT t}• K 1)I)I Ili Keo-std dat& &Oil Applicant JEFFERY GOODSON, 678 MOCKMILL RD, STATESVILLE NC 28677 H:8284618296 HOME:8284618296 Contractor JOHNNY ROYALL, PO BOX 564, YADKINVILLE NC 27055 8:3364632815 Land Owner STONEHAVEN MOBILE HOMES LLC, PO BOX 7, GRANITE FALLS NC 28630 NAME TO APPEAR ON PERMIT Jeffery Goodson SITE ADDRESS: 1278 SHILOH RD, CLAREMONT NC 28610 PIN # 377004819312 NAME of SUBDIVISION: Lot# 3& PT 2 Section/Block PROPERTY SIZE: Square Feet Acres 073 DIRECTIONS: DOWN HWY 10 GOING TOWARD CATAWBA TURN RIGHT ON SHILOH RD PAST CHURCH ON LEFT 1/2 ON L EMPTY LOT(MOBILE HOME BURNED)AND HAS BEEN REMOVED PRIMARY CONTACT: Applicant SEWER TYPE: Septic Tank GALLONS PER DAY: 360 r . : UPPLY: Private Well DESCRIBE WORK: SWITCH OUT OF DOUBLEWIDE 28X8r WITH 6 X6 FRONT, 4X4 REAR AND SIDE DECKS 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? Yes Are there any easements or right-of-ways on this property? APPLICATION FOR: Existing Structure STRUCTURE TYPE: PRIMARY RESIDENCE FACILITY TYPE: Mobile Home OTHER DESCRIPTION: DESCRIPTION OF BURNED DOUBLE WIDE EXISTING STRUCTURES ON SITE (IF ANY) DIM EXISTING STRUCTURE: NUMBER OF EXISTING BEDROOMS: 3 #OF OCCUPANTS: 0 PROPOSED CONSTRUCTION NEW STRUCTURE DIM:: 8X80, 6x6 front, 4x4 side and rear decks #OF NEW BEDROOMS:: Desired system types(Improvement Permit or Authorization to Construct): ACCEPTED: ALTERNATIVE: CONVENTIONAL: OTHER: INNOVATIVE: ANY: YES Other described: E9-chapplicalion 08/02/2016 12:40 Page 1 of 4 IgA CATAWBA COUNTY Case# RBPR-08-2016-24420 Public Health Department Subdivision Q ; X00',�; Environmental Health Division PINY 377004819312 t PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 /g.2 w NAME ON PERMIT: (JEFFERY GOODSON), 678 MOCKMILL RD, STATESVILLE NC 28677 ( Jeffery Goodson) Site Address: 1278 SHILOH RD, CLAREMONT NC 28610 Property Size: Square Feet Acres 0.73 Directions: DOWN HWY 10 GOING TOWARD CATAWBATURN RIGHT ON SHILOH RD PAST CHURCH ON LEFT 1/2 ON L EMPTY LOT(MOBILE HOME BURNED) AND HAS BEEN REMOVED 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 AREA1 FEIit MEltgti 'itIIIi� l.11 fi'J ,b?'.y;11Si1� i,rt9 % Ii7 - . ttlff�1 t 'tri illr!il;1517 711111l� III'Ihlllllill?i u ,� LS , '�1,LIIi11t t� a sig : �r� ' �iDATE �� aIEEE AMOUNTLJ Improvement Permit Fee 08/02/2016 $150.00 t}�1iiiii ''+ � i TomnE• ti�Es°Ifl!I'Ihll!'J".��i1V��o;llhar'u�l0,!..,!!lui�ulIIIII�IiII " ,�IPhIII1 :1:'lllil� l Ill SIeo ool� ,Itul2di'+ ,'w tJtbn 4!nue oilul:'u''inaldlL. L GNUI!illil6I t:3LIil16 111.L. Wtl1131: •_ s 1 FEES ARE NON-REFUNDABLE ONCE A SITE VISIT IS MADE OR WORK ON A PLAN REVIEW HAS COMMENCED SYSTEM REDESIGN ANDIOR RETRIP WILL INCUR AN ADDITIONAL CHARGE (SEE FEE SCHEDULE) E9-chappl i cat ion 08/02/2016 12.40 Page 2 of 4 T HIS THIS IS NOTA PERMIT Case # RBPR-08-2016-24420 CATAWBA COUNTY I EALTH DEPARTMENT �` • �0 X10PLAN REVIEW APPLICATION FOR ENVIRONMENTAL SERVICESor :Residential Building Plan Review - Manufactured Home n •U o.' IMPROVEMENT • y •.'.IC Applicant JEFFERY GOODSON. 678 MOCKMILL RD. STATESVILLE NC 28677 H:8284618296 HONME:8284618296 • Contractor JOHNNY ROYALL. PO BOX 564, YADKINVILLE NC 27055 B:3364632815 Land Owner STONEHAVEN MOBILE HOMES LLC, PO BOX 7, GRANITE FALLS NC 28630 NAME TO APPEAR ON PERMIT Jeffery Goodson SITE ADDRESS: 1278 SHILOH RD. CLAREMONT NC 28610 PIN # 377004819312 NAME of SUBDIVISION: Lot# 3 & PT 2 Section/Block PROPERTY SIZE: Square Feet Acres _ 0.73 DIRECTIONS: DOWN HWY 10 GOING TOWARD CATAWBA TURN RIGHT ON SHILOH RD PAST CHURCH ON LEFT 1/2 ON L EMPTY LOT(MOBILE HOME BURNED) AND HAS BEEN REMOVED PRIMARY CONTACT: Applicant SEWER TYPE: Septic Tank GALLONS PER DAY: 360 WATER SUPPLY: Private Well DESCRIBE WORK: SWITCH OUT OF DOUBLEWIDE 28X80 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? Yes Are there any easements or right-of-ways on this property? APPLICATION FOR: Existing Structure STRUCTURE TYPE: PRIMARY RESIDENCE FACILITY TYPE: Mobile Home OTHER DESCRIPTION: DESCRIPTION OF BURNED DOUBLE WIDE EXISTING STRUCTURES ON SITE (IF ANY) DIM EXISTING STRUCTURE: NUMBER OF EXISTING BEDROOMS: 3 #OF OCCUPANTS: PROPOSED CONSTRUCTION NEW STRUCTURE DIM:: 28X80 #OF NEW BEDROOMS:: 3 Desired system types (Improvement Permit or Authorization to Construct): ACCEPTED: ALTERNATIVE: CONVENTIONAL: OTHER: INNOVATIVE: ANY: YES Other described: E9-chapplication 08/02/2016 11:44 Page 1 of4 ,8A CATAWBA COUNTY RBPR-08-2016-24420 • Case# G Public Health Department Subdivision Environmental Health Division PIN# 377004819312 mss+ PO Box 389. 100-A Southwest Blvd,Newton,NC 28658 l: 2 w NAME ON PERMIT: (JEFFERY GOODSON), 678 MOCKMILL RD, STATESVILLE NC 28677 ( Jeffery Goodson) Site Address: 1278 SHILOH RD, CLAREMONT NC 28610 Property Size: Square Feet Acres 0.73 Directions: DOWN HWY 10 GOING TOWARD CATAWBA TURN RIGHT ON SHILOH RD PAST CHURCH ON LEFT 1/2 ON L EMPTY LOT(MOBILE HOME BURNED)AND HAS BEEN REMOVED 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 a \solely responsible for the proper identification a labelipg of all property lines and corners and making the site acc- side so that a complet ?site eva ation can be performed. Date: — i0 Signature of Applicant or Agent ' ' I ��Z�}� `31� 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 AREA? FEENAME ) DATE `.: :..FEE AMOUNT _i Improvement Permit Fee 08/02/2016 $150.00 TOTAL-FEES $150.00 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-chant'cat ion 08/02/2016 11:44 Page 2 of4 QT+ THIS IS NOT A PERMIT L� Y = . CATAWBA COUNTY HEALTH.DEPARTMENT ` � ;;�� Application for Environmental Services Page I Improvement Permit Authorization to Construct I I Septic Repair Septic Malfunction Li Septic Expansion I I New Well Permit I I Replacement Well In Well Abandonment U • Well Repair ❑ Existing System Inspection (Pre-Approval Required) E Application is for New Construction E Existing Facility Property Address f 7 j{'1 r/ D�j , r� / ) Subdivision I e c Intl 0 n7' / v ' 'i (y"-�D/bLot# Acres Section/Block/Phase Driving Directions to Propert tic b Gce/il Si /0 ho -fb .n b 't-} Ar A idyl/. ickg ;Lc—c- CL2l.I.R.r Z_ 02-0 . 1 ' e.,rt> Z `S i i C/A2r:46, (.q i4 '.-Yc.e_ 6't cea itre49 oQbro ,a 0,0-4(z NAME TO APPEAR ON PERMIT? r Owner I I Applicant I I Contractor Applicant Contact Information Addr �G ? OCk /� �� .. pc L Address /j� tll /� (� ��'t"I"�� ` s? tkic. 2.32p-6-7 ( Phone Cell Phone Owner Contact Information Name Sta afcn NOW- o j Lit it Address Phone I Cell Phone Contractor Contact Information Name a Si `/ Address o oky G 7-A4 K2.a)tfi `Lj e a7/r, j 4-6_,,,Phone-3'2(0 "'(p 1p .a °. I Cell Phone q 3- pi/is WHO WILL BE THE PRIMARY CONTACT? Owner LI Applicant n Contractor Description of Existing Structures on Site'\ )"v—f rc� ) 1rs_. ) # of Bedrooms *j' '' Structure Dimensions 07 'Xt° # of Occupants Basement ❑ Yes �iNo Basement Fixtures 0 Yes ;> . No The Applicant shall notify the local health depai intent 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. p Yes �' Does the site contain any jurisdictional wetlands? *Yes4N AVO Does the site contain any existing wastewater systems? p Yes E��J"No Is any wastewater going to be generated on the site other than domestic sewage? ' Yes R'50 Is the site subject to approval by any other public agency? O Yes 0 No Ape there any easements or right of ways on this property? Describe Existing water supply in use Prindividual Well ❑ Community Well ❑ Semi-Public Well ❑ County/City/Township Water Line Is a public water supply available? ** X 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) 0 Accepted 0 Alternative 0 Conventional 0 Innovative 0 Other > Any FT si1`t 1LJ \ THIS IS NOTA PERMIT ounti 1� CATAWBA COUNTY HEALTH DEPARTMENT • ` ��. . �...-- Nort„c `;�, Application for Environmental Services °Page Proposed Facility Type --f Cat co f Primary Residence New 1 ideaFe n Addition to Residence # of New Bedrooms *t 3 `t 1Ixt, Project Description I cup 1CIIQ t Structure Dimensions c # of Occupants 13 Basement ❑ Yes I. No Basement Fixtures El Yes !l1; No n Accessory Structure(s) Describe #of New Bedrooms *t if applicable Structure Dimensions #of Occupants Accessory Dwelling ❑ Yes No Plumbing ❑ Yes n No Describe Plumbing Needed n Multi-Family Residence#Units #Bedrooms per Unit*t Total#Bedrooms *.f. Structure Dimensions ❑ Food Service Specify Type # Seats Floor Space-Entire Food Service Facility (Sq FO #Employees per Shift #of Shifts Dining Area(Sq.Ft.) ❑ 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 Construction/Abandonment/Repair Proposed Well Type ❑ Individual Well n Semi-Public Well ❑ Community Well Abandonment Type n Drilled ❑ Bored n Dug n 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 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. (.5re_ �%G Signature of Owner or Agent / Date Printed Name of Owner or Agent ( /V0 Catawba County Environmental Health H\C---‘5.- a 2\8A9 mo 970. -- - -11\ 23°' J 22g 8y J m `0 o J J —2 ---- s • 0()o -�- - ro % 2q3 a2 7. o aw 0o J .....a\ J J . J ' ,,\\, NCIN*\\\ Parcel: 377004819312, 1278 SHILOH RD lin=50ft CLAREMONT, 28610 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 08/02/2016 Parcel Report Page 1 of 1 Parcel Report - Catawba County NC Parcel Information: Owner Information: Parcel ID: 377004819312 Owner: STONEHAVEN MOBILE HOMES LLC Parcel Address: 1278 SHILOH RD Owner2: City: CLAREMONT, 28610 Address: PO BOX 7 LRK(REID): 23260 Address2: Deed Book/Page: 3093/1228 City: GRANITE FALLS Subdivision: State/Zip: NC 28630-0007 Lots/Block: 3 & PT 2/ School Information: Last Sale: Plat Book/Page: 18/135 School District: COUNTY Legal: LOT 3 & PT 2 PL 18-135 Elementary School: CATAWBA Middle School: MILL CREEK Calculated Acreage: .730 Tax Map: 023AY 01015 High School: BANDYS Township: CATAWBA School Map State Road #: 1821 TaxNalue Information: Tax Rates(pdf) Zoning Information: City Tax District: All in County Zoning District: COUNTY County Fire District: BANDYS Zoningl: R-40 Building(s) Value: $50,000 Zoning2: Land Value: $12,000 Zoning3: Assessed Total Value: $62,000 Zoning Overlay: DWMH-O,WP-O Year Built/Remodeled: 1983/ Small Area: BALLS CREEK Current Tax Bill Split Zoning Districts: / Zoning Agency Phone Numbers Miscellaneous: Firm Panel Date: 2007-09-05 Building Permits for this parcel. Firm Panel #: 3710377000J Building Details 2010 Census Block: 4009 WaterShed: WS-IV Protected Area 2010 Census Tract: 011402 Voter Precinct: P5 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 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, Catawb- -.unty Government, North Carolina. All rights reserved. I ThirP 3 3 C http://gis.catawbacountync.gov/nomap/parcel_report.php?key=377004819312&typ=P 8/2/2016 CATAWBA COUNTY HEALTH DEPARTMENT NEWTON , NORTH CAROLINA . COMPLETION PERMIT FOR SEPTIC TANKS PERMIT N° 0092 / DATE : —2- !�P rj OWNER -,pini_cLtc Xiitie4 ADDRESS BUILDING C TRACTOR SUBDIVISION `e`at LOCATIoN7Y/0- -4..- en_We naralecti.44yF4iew /. -'LOT ;E 224 M c/l LOT SIZE ' BLOCK OR SECTION HOUSE ( ) MOBILE HOME ( L — BUSINESS ( ) OTHER ( ) FHA-VA LOAN ( ) SEPTIC TANK: (SIZE /cz1 v GALS) WATER SUPPLY : NO . BEDROOMS NO FIXTURES INDIVIDUAL /� PUBLIC GARBAGE DISPOSAL UNIT : YES ( NO ( ) IF WELL, TYPE : BORED DRILLED DUG AUTO WASHING MACHINE : YES ( ) N0 , (. ) DISTANCE FROM SEPTIC TANK OR NEAREST NITRIFICATION FIELD;. /Olt) SQ , FT . POLLUTION : FT. I) NUMBER OF LINES LI SEPTIC TANK INST ED BY : 2) LENGTH AND W.IDTEj,_OF LINES /0k J-YO PERMIT VEE S O< d a) BED SYSTEM ( -� CE: s I Am OF LE"' ' BY : - - -- Th) TRENCH SYSTEM ( ) - - / - / 2. in ( 3) DEPTH OF STONE IN LINES REMA: S : ADEQUATE FALL (GRADE) ON: I) BUILDING/ (HOUSE) SEWER LINE : YES H 2) NITRrAPATION LINES : DATE INSTALLED: t.4. - 7_9-,j)-3 YES NO ( ) SEPTIC TANK LAYOUT • • H U 0 w H 0 HEALTH DEPARTMENT COPY Y ! ' 7/7 u..-- t — 3µ f" CATAWBA COUNTY HEALTH DEPARTMENT _ IMPROVEMENT PERMIT FOR SEPTIC TANGS Permit No. 13721 tHE OF OWNER i•',year. ! �/►:�rpl"!% 2 2 DATE 5j ✓U - 73 )DRESS OF OWNER J ti 2,An 8. . ,t) l0 PHONE 1ME OF CONTRACTOR ADDRESS )CATION p Z, I/ , ad i.` 1 a / ,fcI- ; t?t441t-C p41— MDIVISION Ca-Fte O. 045).._ LOT NO. S SECTION OR BLOCK 3/04 )T .SI : 9 (RAJ r LOAN _ 1 �f SEPTIC TANK LAYOUT )USE �.f� MOBILE HOME BUSINESS ( ) OTHER ( ) I ). BE' 'OOMS �21 NO. FIXTURES (Z} 1RBAGE DISPOSAL UNIT: YES ( ) NO ( y/ ✓ " " t' ' ��/ .UMBING UNDER BASEMENT FLOOR: YES ( ) NO ( ) - Q,y.y ,Li" — CZE OF TANK mew LIQUID GALLONS - ////'''� iTNumber ofEl 1. Number of lines 2. Lengtha and width of lines: a. Bed System /O XQb ft. b. Trench system _ ft. 3. Total Depth of stone /....) inches 3OUNDWATER INTERCEPTOR DRAIN: (IF REQUIRED) ,e-- CEA \TER SUPPLY: PRIVATE V) PUBLIC ( ) , ,/ f\jTif 7NER NOTIFIED TO CHECK ZONING: Y S V") NO ( ) Lir' '1„//// JNER AGREES WITH LAYOUT: YES NO ( ) JNER AGREES WITH SPECIAL INSTRUCTIONS: YES V�O ( ) -------------- INER OR CONTRACTOR SIGNATURE w. 4 ._ 3RMIT FEE S l a t O FQ r ,j 9 3RMZT VOID AFTER 36 MONIS" SEPTIC TANK CONTRACTOR MUST FOLLOW ALL TPROVEMIN3rERMET/ISSel/BY l�/��L DETAILS OF THIS PERMIT (LAYOUT) �2IITARI y / HEALTH DEPARTMENT COPY )IL CLASSIFICATION: SUITABLE ( ) PROVISIONALLY SUITABLE (1) UNSUITABLE ( ) CTE FACTORS: '� SLOPE (%) S -- ES - U 7. SOIL PERMEABILITY S �5)- L SOIL TEXTURE ( 2-48\IN. ) S - PS - U UNDER 60 MIN. - OVER 60 MIN. SANDY, LOAMY, CLAYEY) 8. OTHER S - PS - C . SOIL STRUCTURE 2-48 IN.) S - . - L' (SPECIFY) . SOIL DEPTH (IN.) _S_ -(P,)- U 9. SOIL SERIES: RESTRICTIVE HORIZONS (IN. ) r' SJ'-'P S - U A. CECIL ( ) B. .HIWASSEE ( ) (IMPERVIOUS STRATA, ROCK) C. MADISON ( ) D. APPLING ( ) SOIL DRAINAGE - GROUNDWATER CV- PS - U E. PACOLET ( ) F. FLCOD PLAIN (: ) (EXTERNAL - INTERNAL) G. 2-1 CLAY SOIL H. OTHER-SPECIFY NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES VARIANCE APPLICATION FOR 2C .0100 WELL CONSTRUCTION STANDARDS: PRIVATE DRINKING WATER WELLS UNDER 15A NCAC 02C.0300 WATER SUPPLY WELLS UNDER 15A NCAC 02C.0107 All water supply wells not considered "Private Drinking Water Wells"and including irrigation, industrial,and commercial wells. WELLS OTHER THAN WATER SUPPLY UNDER 15A NCAC 02C.0108 Including monitoring and recovery wells. Print clearly or type information. Illegible submittals will be returned as incomplete. DATER130 20 , 201(1) PERMIT NO.: (to be completed by DWQ/DPH) A. WELL OWNER— For single family residences list the property owner(s). For all others, list name of the business, organization,or government agency and person delegated signature authority: tytti 5k)tru_ k o 0 r ivi o b ie )1,004-e Mailing'Address: 1i� �j r City: kTr�111 pc, State: / �q- , Zip Code? `e County: (a�.�CI WC �l Day Tele No.: 7 0 Y ^ 36) —/p c)? Cell No.: EMAIL Address: Fax No.: B. PHYSICAL LOCATION OF WELL SITE �J(� (1) Parcel Identifica i n Nu ber(PIN)of well site: I / 700 /D / 9 31 County: (2) Physical Address(if different than mailing address): I Q h J el O h �CL City: 1 CJ ..fN WI a k t State: NC Zip Code: d,61 D C. WELL DRILLER INFORMATION (if known) Well Drilling Contractor's Name: NC Well Drilling Contractor Certification No.: Company Name: Contact Person: City: State: Zip Code: County: Day Tele No.: Cell No.: EMAIL Address: Fax No.: Form GW-22V Page'1 Revised February 2013 D. REASON FOR VARIANCE REQUEST — Include type of well(s) to be constructed; rule for which the variance is being requested; description of how the alternate construction will not endanger human health and welfare and the environment; and reason why construction and/or operation in accordance with the standards is not technically feasible and/or provides equal or better protection of the groundwater. 1/25 01 �r a jou: t) -)cI( rS tom( hoWIC E. ATTACHMENTS—Provide the following information as attachments to this application: (1) A map showing general location of the property (including road names, NC State Route Number, distances, any key landmarks, etc.)sufficient for finding the well location. (2) Detailed site map with scale showing location of proposed well relevant to septic system(s), building foundations,property lines,water bodies,potential sources of contamination, other wells, etc. (3) Submit a copy of the local well permit application and site evaluation map(if applicable). (4) Any other information relevant to the variance request such as a well construction diagram showing proposed well liner or atypical construction materials/methods. F. OTHER MINIMUM CONSTRUCTION REQUIREMENTS For water supply wells, approval of a variance will require that additional construction requirements beyond those specified in 15A NCAC 02C .0107 be met. Minimum additional construction requirements for Coastal Plain and Piedmont and Mountain region wells are referenced on Attachments A and B on pages 4 and 5 of this application. Approval of a variance will not be considered in cases where the specified minimum additional construction requirements cannot be met. G. SIGNATURES 6.642en, Signature of Person Responsible for Well Construction(typically the well driller)6—OCC/S eifter,1(Print or Type Full Name of Person Responsible for Well Construction (typically the well driller) Signature of County Environmental Health Specialist Print or Type Full Name of County Environmental Health Specialist Per 15A NCAC 02C.0118 the Secretary of the Division of Water Quality or the Division of Public Health may require submittal of information deemed necessary to make a decision on the variance, may impose conditions as part of the decision, and shall respond in writing to the request within 30 days of receipt of the variance request. A variance applicant who is dissatisfied with the decision of the Director may commence a contested case by filing a petition as described in G.S. 150E-23 within 60 days after receipt of the decision. Form GW-22V Page 2 Revised February 2013 Catawba County Environmental Health \ Ililtill.\ \ \ ,,.....,,\ --L \ (..,,,,,,\S,), \ ...› O ..,--'-'\ c, iii\I: f ill w __ 9 y i n\ .-- . ,/,<A"'"'m'll , , . \ ../\ \ Ss\ l c i.,.yk 7.4 ...,. 9 VV , .. , , \,..e.-44.....: '.\ ,e8p,it ;a ; Parcel: 377004819312, 1278 SHILOH RD 1 in=50ft CLAREMONT, 28610 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 08/29/2016 ,_ „e • j lid 4 • T1.' a tPly FI g f i f, !V / • . . m, +k h y � • .G V. "3 e-� ♦ 1. _7.'.'14'..," ■ ' �5+.�1 rS il C 4.� 't° d ma�yy ; -—I j ",' j,uN ,M e 1 i 1.:-0„\a+,4,: x"54 4" '� I eY l ,", { .4. .. i.-�:ias ,ti p4 s . \ ; f s t Lt ,Yr `rS Julia English From: Julia English Sent: Monday, August 29, 2016 2:51 PM To: John Brooks (john.brooks @dhhs.nc.gov) Cc: Robert Phelps Subject: 1278 SHILOH RD CLAREMONT Attachments: RBPR-08-2016-24420.TIF.pdf Attached is a variance request for above referenced property and 2 photos taken by our EH Specialist, Robbie Phelps. If you need further information from him you may contact him at 828-320-3077. Thank you. Julia English Administrative Assistant II Environmental Health Catawba County Public Health 100A Southwest Blvd Newton NC 28658 828-465-8270 828-465-8276 fax • Confidentiality Statement: The information contained in electronic transmissions is confidential and may be subject to protection under the law,including the Health Insurance Portability and Accountability Act(HIPAA).An electronic transmission is intended for the sole use of the individual or entity to whom it is addressed.If you are not the intended recipient,you are notified that any use,distribution or copying of the message is strictly prohibited.If you received a message in error,please contact the sender immediately by replying to the e-mail and delete the material from any computer 1 Nqk RICHARD 0 . BRAJER r4 g io ec Lary DANIEL STALEY Public Health Director, Division ubi_, Health HEALTH AND HUMAN SERVICES Onsite Water Protection Branch August 31, 2016 Stone Haven Mobile Home PO Box 7 Granite Falls, NC 28638 Re: Approval No. JMB892 Private Well Located Less than 25' from Building Perimeter [Rule 15A NCAC 2C .0107(a)(2)(M)] Property location: 178 Shiloh Rd Claremont, NC 28610 To Whom It May Concern; On August 29, 2016 the On-site Water Protection Branch received your request for a variance from the Well Construction standards, Title 15A North Carolina Administrative Code Subchapter 2C .0100. The request for the variance concerns a water supply well on the referenced property that is proposed to serve a single family dwelling. Part of the structure planned for the property will be within twenty-five feet of the well. Specifically, the variance request grants you permission to use a water supply well at a distance closer than the twenty five foot setback to a building perimeter. Achieving the twenty five foot setback would be difficult given the challenges of the property. Based upon information provided by you, the Catawba County Health Department, it is my finding that based upon current conditions as the site exist today (as well as the current proposal for use of the structure) you meet the conditions necessary for approval of a variance as specified by 15A NCAC .0118 (a) (1) and (2). On that basis and if the following conditions are met, the requested variance is approved: --;>"Nothing Compares""..-;_ ,. ., rieoI t and ,a, .a _or.a.:ce ,.. .i.:;.'. ;r. ,ik,l t..: tr L67L Six _o_k., Pod 1.•342 X,111 Sec .D_ _en..ar. Ra`oi4n, Ciro_i..o 27699 1642 9':.9 7n7 '974 .. :..._ 9 c, 3973 . Page 2 of 4 Stone Haven August 31, 2016 1) The well shall be sampled for the same parameters required of a newly constructed well. If samples indicate contamination, further repairs or treatment will be necessary. 2) No potential sources of groundwater contamination shall be stored near the well-head. 3) No termite treatment shall be applied within twenty five feet of the well, unless alternative methods are approved by the Catawba County Health Department. The granting of this variance is for the well location only. It in no way relieves the owner or agent from other requirements of the North Carolina Well Construction Standards including, but not limited to the requirements in 15A NCAC 2C .0113(b) to repair or to abandon any well which acts as a source or channel for the migration of contamination. This approval does not imply sufficient water quality. Further, the approval does not relieve your responsibility to comply with any other applicable Federal, State, or local laws or regulations. If you have any questions regarding this variance, please contact me at (828) 713- 3335. Sincerely, John M. Brooks R.E.H.S, MS `'-'"Nothing Compares": ._._ Department of Health. and Human Services i Division of Public Health 6G:5 .ix Forks Road I 1712 Mail Service Centex Raleigh, North Carolina 27693-1642 31.9 707-5871 _. 1 919 845 3973 _ i I