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HomeMy WebLinkAboutEHPR-03-2016-23341.TIF I' „.4-5;A •G THIS IS NOT A PERMIT Case# EHPR-03-2016-23341 t,f . • CATAWBA COUNTY HEALTH DEPARTMENT CI 1_ xo + E e " t °sue• PLAN REVIEW APPLICATION FOR ENVIRONMENTAL SERVICES " � � ' 1842 w o Environmental Health Plan Review - OSWP ' ' 0 d itt! s 1' '!y TA;• ABANDONMENT O fl . -. T . Owner KENNETH TEMPLE, 3000 SANDY FORD RD, NEWTON NC 28658 C:828-292-7212 NAME TO APPEAR ON PERMIT Kenneth Temple SITE ADDRESS: 3000 SANDY FORD RD, NEWTON NC 28658 PIN # 372013042044 NAME of SUBDIVISION: Lot# Section/Block PROPERTY SIZE: Square Feel 121,532.40 Acres 2.790 DIRECTIONS: Startown Rd, left on Sandy Ford, .9 miles on right PRIMARY CONTACT: Owner SEWER TYPE: Septic Tank GALLONS PER DAY: 360 WATER SUPPLY: Public Water DESCRIBE WORK: well abandonment 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? APPLICATION FOR: Existing Structure STRUCTURE TYPE: PRIMARY RESIDENCE FACILITY TYPE: House OTHER DESCRIPTION: DESCRIPTION OF residence EXISTING STRUCTURES ON SITE (IF ANY) DIM EXISTING STRUCTURE: 79x27 NUMBER OF EXISTING BEDROOMS: 3 #OF OCCUPANTS: 3 PROPOSED CONSTRUCTION BASEMENT? Yes 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 ABANDONMENT ABANDONMENT TYPE: Dug 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 an orrect. Authorized county and state officials are granted right of entry to conduct necessary inspections to determine compliance with applicable la s d rules. I understand that I am solely resp r sible for the proper identifica on and t Iaatbekng3f 11 A lines and corners and making the site acce le so that a-com.etwstt€-evalua 9 can b/•erformed. Date: / • 1 IjjL ` Signature of Applicant or Agent �� • An Environmental Health Specialist will contact you within 5 working days o"applicatio date, If you need further information or assistance please call 828-466-7291 AREA2 ti tiit t*********tit*****ttttttt ttt**ttttt**ttt#tt*ttttt***tttttittt*t*ititt*t#ttitt**it i t ttttttt ti i*ttt*tttt E9-eliapplication 03/07/2016 15:13 Page 1 of 8 ,:v, 'a CATAWBA COUNTY Case# E1-IPIZ-03-2016-23341 Public Health Department Subdivision ; Environmental Health Division PIN#IIN# 372013042044 PO Box 389. 100-A Southwest Blvd, Newton.NC 28658 lg.2 s�i NAME ON PERMIT: ( KENNETH TEMPLE), 3000 SANDY FORD RD, NEWTON NC 28658 ( Kenneth Temple) Site Address: 3000 SANDY FORD RD, NEWTON NC 28658 Property Size: Square Feet 121,532.40 Acres 2.790 Directions: Startown Rd, left on Sandy Ford, .9 miles on right Iim' „ �II,'FEENAME ir j11I • � 1rilDATE ilEit 14tEF�I Well Abandonment Fee 03/07/2016 5100.00 ali0�l�il� iii 1:11 � TOTALFEES ��n� :r11 ! 1,� j a �� �ill�l,il� �nl t I �� w 1.6t,. W.li. t.l..mW '� .W11UlLL1.L_..7" p°p. i nnn e' to dnv -� irpn � ��r,� 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) ho-rhapplicdtirni 03/07/2016 15:13 Page 2 of 8 CATAWBA THIS IS NOT A PERMIT COUNTY CATAWBA COUNTY HEALTH DEPARTMENT Application for Environmental Services Page I Improvement Permit n Authorization to Construct ❑ Septic Repair❑ Septic Malfunction n Septic Expansion n New Well Permit❑ Replacement Well n Well Abandonment Well Repair n Existing System Inspection (Pre-Approval Required) ❑ Application is for New Construction n Existing Facility K. Property Address ,3000 ?TV D".{ `t , Subdivision N IN)e.. 7 &lo'S ' Lot# Acres Section/Block/Phase Driving Directions to Property NAME TO APPEAR ON PERMIT? 0 Owner ❑ Applicant n Contractor Applicant Contact Information Name Address 5 o ooejq.r t Cr-{ ( 192i {6, "—u N Cs. o aJ Phone Cell Phone 7z&-zcz)Z rf Z! Z, Owner Contact Information Name VN--c—.Q . _ ,.,( e , Address Phone Cell Phone Contractor Contact Information Name License# Address Phone Cell Phone WHO WILL BE THE PRIMARY CONTACT? l Owner n Applicant ❑ Contractor Description of Existing Structures on Site # of Bedrooms *T Structure Dimensions _ # of Occupants Basement ❑ Yes ❑ No Basement Fixtures _ Yes n 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. ❑ Yes No Does the site contain any jurisdictional wetlands? Yes ❑ No Does the site contain any existing wastewater systems? ❑ Yes va No Is any wastewater going to be generated on the site other than domestic sewage? ❑ Yes S'No Is the site subject to approval by any other public agency? ❑ Yes g No Are there any easements or right of ways on this property? Describe Existing water supply in use ® Individual Well n Community Well n Semi-Public Well ® County/City/Township Water Line Is a public water supply available? ** ® Yes n 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 CATAWBA THIS IS NOT A PERMIT cou�r ^- CATAWBA COUNTY HEALTH DEPARTMENT „o,t�,,,n, Application for Environmental Services Page 2 Proposed Facility Type Primary Residence n New Residence ❑ Addition to Residence # of New Bedrooms *t Project Description Structure Dimensions ri X 2-7 # of Occupants Basement ,Yes ❑ No Basement Fixtures n Yes ',No ❑ Accessory Structure(s) Describe # of New Bedrooms *t if applicable Structure Dimensions # of Occupants Accessory Dwelling ❑ Yes n No Plumbing ❑ Yes n No Describe Plumbing Needed n Multi-Family Residence# Units #Bedrooms per Unit*t Total # Bedrooms *t Structure Dimensions n Food Service Specify Type # Seats Floor Space -Entire Food Service Facility (Sq Ft) # 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 °k OAR"—— Cr'C 2 c--((j S_ Proposed Well Type ® Individual Well n Semi-Public Well n Community Well ler Ala u ncQ,on : -t o n L� Abandonment Type ❑ Drilled n Bored ® Dug Ti Unknown " - �v7� Well Repair Requested n 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. Signature of Owner or Agent cQJ� Date C° u.\ `-/ ( b nil Printed Name of Owner or Agent \C C0--\ • Catawba County Environmental Health .1095 ` 125.01:_ 37� 1211 = II\ \\,____42 --- r_ ,_ _; • 81 52.4 oi _= _ _- _ - -- -_ --- --f r ' 18 . - a# _ ___ — :-----_ :,071 ii. 1. 90. 4 431) _ __ am' :.,.., � �.' . ' ^� --�_ "'P'7 `f 057 . All!" ,� - —C4-- •302 `-' . ' O mit U. a . •3 ^ -may i ------(\ 8 •1039 ki ar F - ki • 1 .37 78)L. O7) ■ , '- . �` .10 ... - I 40 I, 179) .3011 (22) \in? I ,--' Parcel: 372013042044, 3000 SANDY FORD RD 1 in=100ft NEWTON, 28658 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 03/07/2016 Page 1 of 1 Parcel Report-Catawba County NC Parcel Information: Owner Information: Parcel ID:37 201 304 20 44 Owner:TEMPLE KENNETH DARRELL JR Parcel Address:3000 SANDY FORD RD Owner2:TEMPLE JULIE B City:NEWTON,28658 Address:3000 SANDY FORD RD LRK(REID):31267 Address2. Deed Book/Page: 1825/0896 City:NEWTON Subdivision: State/Zip:NC 28658-9201 Lots/Block:/ Last Sale:$96,500 on 1993-04-01 School Information: School District:COUNTY Plat Book/Page: Legal:3000 SANDY FORD RD Elementary School:STARTOWN Middle School:JACOBS FORK Calculated Acreage:2.790 Tax Map:049N 02023 High School:MAIDEN School Map Township:NEWTON State Road#: 1143 TaxNalue Information:Tax Rates(pdt) Zoning Information: City Tax District.All in County Zoning District:COUNTY County Fire District:HICKORY RURAL Zoningl:R-20 Building(s)Value:$154,400 Zoning2: Land Value:$28,200 Zoning3: Assessed Total Value:5182,600 Zoning Overlay: Year Built/Remodeled. 1980/2003 Small Area:STARTOWN Current Tax Bill Split Zoning Districts./ Zoning Agency Phone Numbers Miscellaneous: Firm Panel Date:2007-09-05 Building Permits for this parcel. Firm Panel k:3710372000J Building 2010 Census Block: 1049 WaterShed: 2010 Census Tract 011701 Voter Precinct:P34 Agricultural District: Parcel Report Data Descriptions List all Owners Deed History Report Assessment Reoort Tay nxprepoe product was prepared from lye cala'/r County,NC Geospatei Int onnation Scones calawM Cowl,has mad.suyrstantial allude b ensure the amuecy oI lomtm and Noelrg Ntomrallon enlai led on the may ordata on Ibis'port Cameos County pmawtas and nurommMds the IMepantlm l vonlirnlen of any data cmpms on this map/report product by the veer-The County of Catawba,its espbyees,aunts,and personnel,die/atn.and shall not ea held liable for any and all damages,loss or liability.whether dined,indeed or consequential Mid,edsos or may arse from ibis map/rotted product or the use there l by any Pmmn od entity. ©2016,Catawba County Government,North Carolina.All rights reserved. 3/7/2016 A- Co CATAWBA COUNTY C. I00A SOUTHWEST BLVD T K , NEWTON,NORTH CAROLINA 28658 INVOICE/RECEIPT Q uskatraitr. sV>e PHONE: 828.465.8399 C) V, vaw \ hyr . \$42 sM www.catawbacountyne.gov Monday, March 7, 2016 Invoice Number: 03-16-325913 Invoice Date: 03/07/2016 EHPR-03-20 1 6-2 3 3 4 1 CASE TYPE: Environmental Health Plan Review WORK CLASS: OSWP SITE ADDRESS: 3000 SANDY FORD RD, NEWTON NC 28658 Owner KENNETH TEMPLE, 3000 SANDY FORD RD, NEWTON NC 28658 C:828-292-7212 ** NO PEOPLESOFTACCOUNTASSIGNED ** PAYOR: Temple, Kenneth FEES EHPR-03-2016-23341 FEE AMT DUE AMT Well Abandonment Fee 03/07/2016 $100.00 $0.00 FEES: $100.00 $0.00 TOTAL FEES : $100.00 $0.00 PAYMENTS INVOICE NUMBER FEE NAME FEE AMOUNT TRANSACTION NUMBER: TRC-633444-07-03-2016 PAYMENT DATE : 03/07/2016 PAYMENT TYPE: Credit Card 159089209 03-16-325913 Well Abandonment Fee 5100.00 TOTAL PAYMENTS : $100.00 invoicereceipt 03/07/2016 15:12 Page 1 of I