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HomeMy WebLinkAboutEHPR-04-2016-23665.TIF qA O THIS IS NOT A PERMIT Case # EHPR-04-2 0 1 6-23 665 CATAWBA COUNTY HEALTH DEPARTMENT .o. �*a `3 M (3 Mr. REVIEW APPLICATION FOR ENVIRONMENTAL SERVICES p 1842 sM Environmental Health Plan Review - Septic Malfunction o o AUTH_CONST - SEPTIC_MALFUNCTION -: to n - Owner MICHAEL BRADSHAW, 2620 23RD AV NE, HICKORY NC 28601 H:8283242776 C:8283089872 HOME:8283242776 NAME TO APPEAR ON PERMIT Michael Bradshaw SITE ADDRESS: 2620 23RD AV NE, HICKORY NC 28601 PIN # 372306373909 NAME of SUBDIVISION: ST STEPHENS PARK Lot# 15 Section/Block PROPERTY SIZE: Square Feet 23,522.40 Acres 0.54 DIRECTIONS: North on Mcdonald Parkway, Left onto Springs Road, Left onto 25th St Dr NE, 1st house on the Right PRIMARY CONTACT: Owner SEWER TYPE: Septic Tank GALLONS PER DAY: 360 WATER SUPPLY: Private Well DESCRIBE WORK: Water is puddling in spots on property. 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 EXISTING STRUCTURES ON SITE(IF ANY) DIM EXISTING STRUCTURE: 26x52 NUMBER OF EXISTING BEDROOMS: 3 #OF OCCUPANTS: 2 PROPOSED CONSTRUCTION BASEMENT? Yes BASEMENT FIXTURES? Yes 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 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 o th-t a c. 'plete site ev- s ation C. 4,- performed. Date: %2/—/5 -,20/( Signature of Applicant or Agent � .,� /!it - 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 AREA2 1:9-ell ppl lea:un 04/15/2016 16:00 Page 1 of 7 CATAWBA COUNTY Case# EHPR-04-20 1 6-23 66 5 ,Q' ti L Public Health Department Subdivision ST STEPHENS PARK Y Environmental Health Division PINdt 372306373909 "•nh PO Box 389. 100-A Southwest Blvd.Newton_NC 28658 /g.2 S, NAME ON PERMIT: (MICHAEL BRADSHAW), 2620 23RD AV NE, HICKORY NC 28601 ( Michael Bradshaw) Site Address: 2620 23RD AV NE, HICKORY NC 28601 Property Size: Square Feet 23,522.40 Acres 0.54 Directions: North on Mcdonald Parkway, Left onto Springs Road, Left onto 25th St Dr NE, 1st house on the Right ��IP(GHI�a1pf41<I�1 I't ` 11,1jur'' , . . I �i( F S 1iim 11 ( ii f K i ilfllli(NIh� hf�i 1 FEENAMEI� �I�I���I °,t t, �' 4�DATE'J ��lti� FEEIAMOUNT: Authorization to Construct (Repair) Fee 04/15/2016 $300.00 N�11 (TOTALI�REES ;yl • ilfli�l111��111��1i? .�illl���i�l' I)iiiIiI�� �$30000,�,9J �rl�itl,��1�I�iI �1 IIIIltl i ' :`1 iP i>..1:.1iL riGu111 e �w... stimmani 1 1WH�Nuu—.,!IIIIO'�':r ✓r.Il 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) I_J-ehapplication 04/15/2016 16:00 Page 2 of 7 CATAWBA THTS IS NOT A PERMIT coun �, r CATAWBA COUNTY HEALTH DEPARTMENT Application for Environmental Services Page 1 Improvement Permit❑ Authorization to Construct❑ Septic Repair ❑ Septic Malfunction (c Septic Expansion ❑ New Well Permit❑ Replacement Well ❑ Well Abandonment❑ Well Repair ❑ Existing System Inspection (Pre-Approval Required) ❑ Application is for New Construction Property Address2620 23rd Ave. NE ❑ Existing Facility ❑ Hickory, NC. 28601 Subdivision Lot# 15 Acres Driving Directions to Property North on McDonald Parkway,left onto Springs Rd.left onto 25th St.D NE Section/Block/Phase ont�pd,Ave.N E. first house an the right NAME TO APPEAR ON PERMIT? ® Owner n Applicant Applicant Contact Information n Contractor Name Michael C. Bradshaw Address 2620 23rd Ave. NE. Hickory, NC. 28601 Phone 828-324-2776 Owner Contact Information Cell Phone 828_308-9872 Name Same as above Address Same as above Phone Contractor Contact Information Name Address Phone Cell Phone WHO WILL BE THE PRIMARY CONTACT? Owner Description of Existing Structures on Site single ramuydwell nch style ❑ Applicant Contractor # of Bedrooms * 3 7 Structure Dime lions 26' X52' Basement 19 Yes #of Occupants 2 ❑ No Basement Fixtures Yes No The n .he 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. X® Yes No Does the site contain any jurisdictional wetlands? Yes 0 No Does the site contain any existing wastewater systems? ® Yes 0 No Is any wastewater going to be generated on the site other than domestic sewage? O Yes 0 No Is the site to a subject ® Yes 0 No subject approval by any other public agency? Are there any easements or right of'ways on this properly? Describe Existing water supply in use 0 Individual Well / Community Well Semi-Public Well ❑ 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 Types : (systems can be ranked in order of your preference) ( ) ❑ Accepted ❑Alternative IN Conventional ❑ Innovative ❑ Other 0 Any CATAWBA THIS IS NOT A PERMIT COUNTY COUNTY HEALTH DEPARTMENT u , ' Application for Environmental Services Proposed Facility T Ype Page 2 0 Primary Residence ❑ New Residence ❑ Addition to Residence # of New Bedrooms Project Description Replace existing septic system t Structure Dimensions 26'X 52' Basement #of Occupants 2 Yes ❑ No Basement Fixtures ® Yes ® No �- Accessory Structure(s) Describe #of New Bedrooms *I- if applicable.___ # of Occupants Structure Dimensions�_ Plumbing Accessory Dwelling ❑ Yes ❑No b ❑ 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 #Employees per Shift (Sq Ft) #of Shifts Dining Area (Sq. Ft.) Business Specific Type of Business #of Employees per Shift # Retail Floor Space 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 Abandonment T e ❑ Semi-Public Well ❑ Community Well YP ❑ Drilled ❑ Bored Well Repair Requested ❑ Yes ❑ Dug ❑ Unknown ❑ No Describe Calculated Design Flow, Commercial f design flow from certain facilities. This value will be determined during consul ati n awiitth on-site staffdetermine *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 , / �.Llv✓ : s"— Date Zf 76 Printed Name of Owner or Agent d ' /. e/ (jZ et d Catawba County Environmental Health ..77"--ks by 0 • v° 2 A • vb\\.,�V�'1 'P�. 44.56 03 40 9L 4 • 45,56 in J 60 CI\ N „,,, • . �, N� • Q !:, 93.55 r . a -woo_152.35 cz, \ rych 4,' '.....11S 3 . ti n40 no 0 `a' 148,6g 27.25 v 178.9 • 21.8 a „...,,:,,A 030 20 Parcel: 372306373909, 2620 23RD AV NE 1 in=50ft HICKORY, 28601 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 04/15/2016 Parcel Report Page 1 of 1 Parcel Report - Catawba County NC Parcel Information: Owner Information: Parcel ID: 372306373909 Owner: BRADSHAW MICHAEL C Parcel Address: 2620 23RD AV NE Owner2: BRADSHAW LINDA K City: HICKORY, 28601 Address: 2620 23RD AVE NE LRK(REID): 53971 Address2: null Deed Book/Page: 2369/1113 City: HICKORY Subdivision: ST STEPHENS PARK State/Zip: NC 28601-3161 Lots/Block: 15/ null School Information: Last Sale: $128,000 on 2002-06-14 Plat Book/Page: 12/77 School District: COUNTY Elementary School: CLYDE CAMPBELL Legal: null Calculated Acreage: .540 Middle School: ARNDT Tax Map: 157H 01054 High School: ST STEPHENS Township: HICKORY School Map State Road #: 1659 TaxNalue Information: Tax Rates(pdf) Zoning Information: City Tax District: All in County Zoning District: HICKORY County Fire District: ST STEPHENS Zoningl: R-2 Building(s) Value: $128,400 Zoning2: null Land Value: $17,600 Zoning3: null Assessed Total Value: $146,000 Zoning Overlay: null Year Built/Remodeled: 1970/null Small Area: null 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 #: 3710372300J Building Details 2010 Census Block: 1034 WaterShed: null 2010 Census Tract: 010303 Voter Precinct: P30 Agricultural District: 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, Catawba County Government, North Carolina. All rights reserved. .4 ached C cc u ra http://gis.catawbacountync.gov/nomap/parcel_report.php?key=372306373909&typ=P 4/15/2016 5A CATAWBA COUNTY �' / 7A 100ASOUTHWESTBLVD / A NEWTON, NORTH CAROLINA 28658 RECEIPT muvds �� PHONE: 828.465.8399 Friday, April 15, 2016 � � 184'Z sm www.calawbacountync.gov PAYOR: Bradshaw, Michael PAYMENTS TRANSACTION NUMBER: TRC-655996-15-04-2016 PAYMENT DATE : 04/15/2016 PAYMENT TYPE: Credit Card INVOICE NUMBER FEE NAME FEE AMOUNT 04-16-327290 Authorization to Construct (Repair) $300.00 Fee TOTAL PAYMENTS : $300.00 EHPR-04-2016-23665 CASE TYPE: Environmental Health Plan Review WORK CLASS: Septic Malfunction SITE ADDRESS: 2620 23RD AV NE, HICKORY NC 28601 Owner MICHAEL BRADSHAW, 2620 23RD AV NE, HICKORY NC 28601 H:8283242776C:8283089872 ** NO PEOPLESOFT ACCOUNT ASSIGNED ** receipt 04/15/2016 15:59 Page 1 of 1