HomeMy WebLinkAboutEHPR-02-2016-23176.TIF �$A . ) THIS IS NOT A PERMIT Case # EHPR-02-2016-23176
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" CATAWBA COUNTY HEALTH DEPARTMENT 0 •ot 0
`) ",r PLAN REVIEW APPLICATION FOR ENVIRONMENTAL SERVICES � y$F ti " : i
842 �sM Environmental Health Plan Review - Septic Malfunction I o U o r:
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Applicant ID WOODRUFF, 4707 DICK WILSON RD, DENVER NC 28037
H:7044832241 C:7043398746 HOME:7044832241
NAME TO APPEAR ON PERMIT
SITE ADDRESS: 8883 SHERRILLS FORD RD, SHERRILLS FORD NC 28673 PIN # 461701097362
NAME of SUBDIVISION: Lot ft Section/Block
PROPERTY SIZE: Square Feet 40,075.20 Acres 0.92
DIRECTIONS: Hwy 16, to Hwy 150, Sherrills Ford Rd, at the corner of Sherrills Ford & Gregory Rd
PRIMARY CONTACT: Owner SEWER TYPE: Septic Tank
GALLONS PER DAY: 240 WATER SUPPLY: Private Well
SCRIBE WORK: Septic was failing. Replacement pump was needed for repair. EH-10-2015-5737
'Pump has already been replaced without permit.
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: Mobile Home OTHER DESCRIPTION:
DESCRIPTION OF Mobile home 14x80
EXISTING STRUCTURES
ON SITE (IF ANY)
DIM EXISTING STRUCTURE:
NUMBER OF EXISTING BEDROOMS: 2 -1 #OF OCCUPANTS: 3
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:
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 lawspd)rules. I nderstand that I am sol- 'responsible for the
proper identification nd labeling of all property lines and corners and making the site acces;ib a so tha a co ..le e'slte -valu- - .- serformed.
Date:'—/jj Signature of Applicant or Agent -4 4,--tf.t a
An Environmental Health Specialist will contact you within 5 working days of appl . is date.
If you need further information or assistance please call 828-466-7291
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09-ehapplication 04/01/2016 09:28 Page 1 of 7
/A CATAWBA COUNTY Case a EHPR-02-2016-23176
�¢ �L Public Health Department Subdivision
< M Environmental Health Division PINµ
461701097362
PO Box 389, 100-A Southwest Blvd, Newton,NC 28658
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NAME ON PERMIT:
Site Address: 8883 SHERRILLS FORD RD, SHERRILLS FORD NC 28673
Property Size: Square Feet 40,075.20 Acres 0.92
Directions: Hwy 16, to Hwy 150, Sherrills Ford Rd, at the corner of Sherrills Ford& Gregory Rd
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Authorization to Construct(Repair) Fee 02/09/2016 $150.00
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FEES ARE NON-REFUNDABLE
ONCE A SITE VISIT IS MADE OR
WORK ON A PLAN REVIEW HAS COMMENCED
SYSTEM REDESIGN ANDIOR RETRIP WILL INCUR AN ADDITIONAL CHARGE
(SEE FEE SCHEDULE)
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