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HomeMy WebLinkAboutEHPR-05-2016-23926.TIF Y A THIS IS NOT A PERMIT Case # EHPR-05-2016-23926 Qt�;, CATAWBA COUNTY HEALTH DEPARTMENT o ,� ;o• • t U�' q L�jpi PLAN REVIEW APPLICATION FOR ENVIRONMENTAL SERVICES w• teei 842 sM Environmental Health Plan Review - Septic Malfunction lo�ro o jr AUTH CONST- SEPTIC_MALFUNCTION •0 rr: ti of Owner THOMAS WITHERSPOON, 3257 BETHANY CHURCH RD, CLAREMONT NC 28610 H:8284646913 C:8288505051 HOME:8284646913 NAME TO APPEAR ON PERMIT Thomas Witherspoon SITE ADDRESS: 3257 BETHANY CHURCH RD, CLAREMONT NC 28610 PIN # 376005176860 • NAME of SUBDIVISION: Lot# Section/Block PROPERTY SIZE: Square Feet 38,768.40 Acres 0.89 DIRECTIONS: HWY 10 East, Left at Witherspoon Crossroads onto Bethany Church Rd. 2nd house on Left. Dark brown wood 2 story house. PRIMARY CONTACT: Owner SEWER TYPE: Septic Tank GALLONS PER DAY: 360 WATER SUPPLY: Private Well DESCRIBE WORK: Water is on the ground. Tank last pumped 5/9/16. 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: 53x45 NUMBER OF EXISTING BEDROOMS: 3 #OF OCCUPANTS: 2 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 law-span rules. I understand that I am solely responsible for the proper identification apd labeling of all property lines and corners and making the site acre ibl po-that a complete site'el//ua�tio�n"caryn-b,{�e,�performed. Date: {—�3' /6 Signature of Applicant or Agent //��f20�— /�Q 2Z- / li L-� An Environmental Health Specialist will contact you within 5 working days of application d e. If you need further information or assistance please call 828-466-7291 AREA2 E9-ehappli cation 05/23/2016 13:26 Page 1 of7 r° • CATAWBA COUNTY Case# EHPR-05-2016-23926 ,4 'iPy Public Health Department Subdivision d %' t 4. Environmental Health Division PIN# 376005176860 c.t? PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 /g.2 NAME ON PERMIT: (THOMAS WITHERSPOON), 3257 BETHANY CHURCH RD, CLAREMONT NC 28610 ( Thomas Witherspoon) Site Address: 3257 BETHANY CHURCH RD, CLAREMONT NC 28610 Property Size: Square Feet 38,768.40 Acres 0.89 Directions: HWY 10 East, Left at Witherspoon Crossroads onto Bethany Church Rd. 2nd house on Left. Dark brown wood 2 story house. � fIM @i���i1tM ul. I�t� 'i �2 rl[ i' I�Il'fi , o 1. rii��Illlll�l �,�!n� . tip i irprnia11surra0 ;EEENAMEk', ,, Sill lip giq�.�dnut , fi t �l IIlI�II�IIII lW'DATE =x Np2FEE AMOUNTS: Authorization to Construct (Repair) Fee 05/23/2016 $300.00 4I�1ih��Ill'�i I, 1 oTn ,,ESr!liIGIN!IlllwllW,illlll lli lllll1111"pll°llllIllllllNllillil llllllllllllillllllulii' $moo ooi � ililr ;�IIItI, adIniiimd 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) 1:9-eliapplication 05/23/2016 13:26 Page 2 of 7 THIS IS NOT A PERMIT ����� IA CATAWBA COUNTY HEALTH DEPARTMENT counn�,,�•- Page 1 „,„„.o,o;` Application for Environmental Services a g Improvement Permit❑ Authorization to Construct❑ Septic Repair n Septic Malfuncti6? Septic Expansion ❑ New Well Permit n Replacement Well ❑ Well Abandonment _ ��/ Well Repair ❑ Existing System Inspection (Pre-Approval Required) ❑ Application iss for New Construction Existing Facility r Property Address '3 )/ 8P(A/ fritg ei k Subdivision ff (aVTM7I .t _/// Lot# Acres Section/B ock/Phase . _ / Driving Directions to Property . i I A — ` — cl'ta/'k �It� ALAI -Onairhe' Vii_ - / j _� 1_, 7i// i / '_ . InvA it i. NAME TO APPEAR ON PERMIT? ,N Owner ❑ Applicant ❑ Contractor Applicant Contact Information Name 1:A/7/77/95 0)y e 5 /mil i� Address / ip, kit f gi1 fiy, Sm o,, y y Phone Cell Phone Owner Cout ct Information Name /r/'-� (j_4,7-- °)-' r„,A/ Address �7� l ��F,-) ,l2/d (2.4/074 ��G�Oy}LZ y�� Phone y —a/ s - _,(71. 1' Cell Phone � 'QCO-�J✓� Contractor Contact Information Name Address Phone Cell Phone WHO WILL BE THE PRIMARY CONTACT? ❑ Owner H Applicant I Contractor Description of Existing Structures on Site / 1` # of Bedrooms *f Structure Dimensions'?' XL-1 \ # of Occupants 2j Basement El Yes ] No Basement Fixtures 0 Yes a 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 j'B,No Does the site contain any jurisdictional wetlands? WYes ICI No Does the site contain any existing wastewater systems? 0 Yes allo Is any wastewater going to be generated on the site other than domestic sewage? ICI Yes 53 No Is the site subject to approval by any other public agency? a Yes To Are there any easements or right of ways on this property? Describe Existing water supply in use ❑X 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 Type(s): V (systems can be ranked in order of your preference) ❑ Accepted ❑ Alternative ❑ Conventional ❑ Innovative ❑ Other Any c ATA A THIS IS NOT A PERMIT cou��r�°, �--�.�� CATAWBA COUNTY HEALTH DEPARTMENT Application for Environmental Services Page 2 Proposed Facility Type n Primary Residence n New Residence n Addition to Residence # of New Bedrooms *j Project Description Structure Dimensions # of Occupants Basement n Yes Li No Basement Fixtures 0 Yes D No Accessory Structure(s) Describe #of New Bedrooms *t if applicable Structure Dimensions # of Occupants Accessory Dwelling n Yes n No Plumbing n Yes n No Describe Plumbing Needed I Multi-Family Residence#Units ((Bedrooms per Unit*f Total #Bedrooms *t Structure Dimensions I I Food Service Specify Type # Seats Floor Space-Entire Food Service Facility (Sq Ft) #Employees per Shift # of Shifts Dining Area (Sq. Ft.) I I Business Specific Type of Business Retail Floor Space # of Employees per Shift # of Shifts ❑ Other Facility Type Specify If Church# of Seats Kitchen ❑ Yes n No If Daycare Specify Occupancy Application for Well Construction/Abandonment/Repair Proposed Well Type ❑ Individual Well n Semi-Public Well n Community Well Abandonment Type ❑ Drilled n Bored n Dug ❑ Unknown 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. f 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. /, /.1- Signature of Owner or Agent ��J'r'�— Date 23 ,/}� c� j Printed Name of Owner or Agent 0!! ' /�/7-' CY (f2, Catawba County Environmental Health • 03271 4y / ce 219,7 / n 1� / I11 / g- UT J� US ny c m Vs"219.56 r� I / / / / / ! / Parcel: 376005176860, 3257 BETHANY 1 in=50ft CHURCH RD 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 05/23/2016 Parcel Report Page 1 of 1 Parcel Report - Catawba County NC Parcel Information: Owner Information: Parcel ID: 376005176860 Owner: WITHERSPOON THOMAS J Parcel Address: 3257 BETHANY CHURCH RD Owner2: null City: CLAREMONT, 28610 Address: 3257 BETHANY CHURCH RD LRK(REID): 38637 Address2: null Deed Book/Page: 1316/0654 City: CLAREMONT Subdivision: State/Zip: NC 28610-9556 Lots/Block: / School Information: Last Sale: $4,000 on 1982-04-01 Plat Book/Page: School District: COUNTY Legal: PT SHARE 2 WITHERSPO Elementary School: CLAREMONT Middle School: RIVER BEND Calculated Acreage: .890 Tax Map: 074N 02024D High School: BUNKER HILL Township: NEWTON School Map State Road #: 1722 Tax/Value Information: Tax Rates(pdf) Zoning Information: City Tax District: All in County Zoning District: COUNTY County Fire District: CLAREMONT RURAL Zoningl: R-20 Building(s) Value: $159,200 Zoning2: null Land Value: $13,100 Zoning3: null Assessed Total Value: $172,300 Zoning Overlay: WP-O Year Built/Remodeled: 1983/null Small Area: CATAWBA 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 #: 3710376000J Building Details 2010 Census Block: 1057 WaterShed: WS-IV Protected Area 2010 Census Tract: 011401 Voter Precinct: P22 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 at 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. http://gis.catawbacountync.gov/nomap/parcel_report.php?key=376005176860&typ=P 5/23/2016 CATAWBA COUNTY HEALTH DEPARTMENT NEWTON, NORTH CAROLINA COMPLETION PERMIT FOR SEPTIC TANKS PERMIT N_ 4 4 5 7 ,, �;'/ �/� DATE : ,—/7-83 OWNER j (. C�C�rDDRESS BUILDING CONTRACTOR X SUBDIVISION LOCATION 7Y /o tpT-4,0.1 '!44,t/.f�7'�- )<'FC75' 4 --LOT LOT SIZE / �Q / BLOCK OR SECTION HOUSE (1 MOBILE HOME ( ) BUSINESS ( ) OTHER ( ) FHA-VA LOAN ( ) SEPTIC TANK: (SIZE /5"0 D GALS) WATER SUPPLY: NO. BEDROOMS '„L NO FIXTURES 2 , INDIVIDUAL L/ PUBLIC GARBAGE DISPOSAL UNIT:YES ()NO ( IF WELL, TYPE : BORED DRILLED DUG AUTO WASHING MACHINE : YES NO ( ) DISTANCE FROM SEPTIC TANK OR NEAREST NITRIFICATION FIELD: 5'0 0 SQ .FT. POLLUTION : f "-f FT. 1) NUMBER OF LINES 5 SEPTIC TANK INSTALLED BY : 2) LENGTH AND/WIDTH OF (LINES A RZ- X bia , PERMIT FEE $5� a) BED SYSTEM CERi ICAT; 0 •f'LETIO ,BY: b) TRENCH SYSTEM ( ) . Iy /i 3) DEPTH OF STONE IN LINES /2— _ REMA•i : ADEQUATE FALL (GRADE) ON: 1) BUILDIIN!V(HOUSE) SEWER LINE : YES (L1 NO ( ) 2) NITRI�FIA TION LINES : DATE INSTALLED: YES Q/) NO ( ) SEPTIC TANK LAYOUT H � U W E7 H 0 O 11 W AL1F4 DEPARTMENT COPY C �_ CATAWBA COUNTY HEALTH DEPARTMENT & IMPROVEMENT PERMIT FOR SEPTIC TANKS /ItIi Permit No. 13511 NAME OF OWNER 1e ) i (/O /j9 f�J�ry, "�yy"�//� ��pD�ATEn f//2if J ADDRESS OF OWNER 67,, g /, /a_y� 69720,/e7) Mr PHONE NAME OF CONTRACTOR n ADDRESS , ` r � . LOCATION -1-�-/r5 I.�z-e.7iD�,¢-C/.L1i�rvl�i�_ (�'Ze9zaPii _ _�t� Cry" }-e%/&Yi-nniteito —� SUBDIVISION / LOT NO. SECTION OR BLOCK LOT SI E d(UY A- AFHA, VA LOAN HOUSE MOBILE HOME ( ) BUSINESS ( ) OTHER ( ) SEP f% TANK LAYOUT NO. BEDROOMS ca., NO. FIXTURES (_- ///j2," GARBAGE DISPOSAL UNIT: YES NO ( ) / // ( p PLUMBING UNDER B NT FLOOR: YES ( ) NO r ; l lc 6Q /. SIZE OF TANK V O LIQUID GALLONS CO) / NITRIFICATION FIELD: . 1. Number of lines .1) 2. Length and width of lines: a. Bed System nrc Xj £i 0 ft. b. Trench system ft. _ 41 p � 3. Total Depth of stone / 2, inches GROUNDWATER INTERCEPTOR DRAIN: (IF REQUIRED) WATER SUPPLY: PRIVATE ( ) PUBLIC ( ) 22 OWNER NOTIFIED TO CHECK ONIES: YES Q ( ) �6p OWNER AGREES )EES WITH LAYOUT: YES (X) NO ( OWNER AGREES WITH SPECIAL INSTRUCTIONS: YES ( ) NO ( ) OWNER OR CONTRACTOR SW NATURE r / p "(4)toe.. `� r -rvL,, PERMIT FEE $ iCS� "a e({ i -4-i-4- 1 PERMIT VOID AFTER 36 MONTHS IMPROVEMENT PERMIT ISSUED BY SEPTIC TANK CONTRACTOR MUST FOLLOW ALL �y DETAILS OF THIS PERMIT (LAYOUT) SANITARIAN ✓J(/2 7iG7J1/4/ ; HEALTH DEPARTMENT COPY SOIL CLASSIFICATION: SUITABLE ( ) PROVISIONALLY SUITABLE (V) UNSUITABLE ( ) SITE FACTORS: JJ1iYY 1. SLOPE (%) S :- PS - U 7. SOIL PERMEABILITY S - PS - U 2. ri.TEXTURE (C.) S - PS - U UNDER 60 MIN. - OVER 60 MIN. , LOAMY,E(CLAYEY 8. OTHER S - PS - U 3. STRUCTUR 48 IN.) S - PS - U (SPECIFY) 4. SOIL DEPTH (IN.) S - PS - U 9. SOIL SERIES: 5. RESTRICTIVE HORIZONS (IN.) S - PS - U A. CECIL ( ) B. HIWASSEE ( ) (IMPERVIOUS STRATA, ROCK) C. MADISON ( ) D. APPLING ( ) 6. SOIL DRAINAGE - GROUNDWATER S - PS - U E. PACOLET ( ) F. FLOOD PLAIN ( ) (EXTERNAL - INTERNAL) G. 2-1 CLAY SOIL H. OTHER-SPECIFY �'A CATAWBA COUNTY [7 .a 4 O�rt 100A SOUTHWEST BLVD s..� NEWTON, NORTH CAROLINA 28658 RECEIPT 5'•wp,� sa,Pe PHONE: 828.465.8399 v oaea, Monday, May 23, 2016 1842 sm www.catawbacountync.gov PAYOR: Witherspoon, Thomas PAYMENTS TRANSACTION NUMBER: TRC-677800-23-05-2016 PAYMENT DATE : 05/23/2016 PAYMENT TYPE: Cash INVOICE NUMBER FEE NAME FEE AMOUNT 05-16-328620 Authorization to Construct (Repair) $300.00 Fee TOTAL PAYMENTS : S300.00 EHPR-05-2016-23926 CASE TYPE: Environmental Health Plan Review WORK CLASS: Septic Malfunction SITE ADDRESS: 3257 BETHANY CHURCH RD, CLAREMONT NC 28610 Owner THOMAS WITHERSPOON, 3257 BETHANY CHURCH RD, CLAREMONT NC 28610 H:8284646913C:8288505051 ** NO PEOPLESOFT ACCOUNT ASSIGNED ** receipt 05/23/2016 13:25 Page I of I