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HomeMy WebLinkAboutEHPR-06-2016-24110.TIF y $A THIS IS NOT A PERMIT Case # EHPR-06-2016-24110 ; A Q, F-46,71 y CATAWBA COUNTY HEALTH DEPARTMENT 0 y o' A 0 Cr I PLAN REVIEW APPLICATION FOR ENVIRONMENTAL SERVICES 1842 sM Environmental Health Plan Review - OSWP 'o _ o 13 14 relo: IMPROVEMENT 0 13 lay Applicant HAYDEN THORNBURG, PO BOX 3443,HICKORY NC 28603 H:8283282936 C:8282386398 HOME:8283282936 Owner GEORGETTA LUCAS,2165 MOSS FARM RD, HICKORY NC 28602 NAME TO APPEAR ON PERMIT Georgetta Lucas SITE ADDRESS: 2143 MOSS FARM RD, HICKORY NC 28602 PIN # 279114441770 NAME of SUBDIVISION: Lot ft 2 Section/Block PROPERTY SIZE: Square Feet 130,680.00 Acres 3.00 DIRECTIONS: From Hwy 127 South, Right onto Moss Farm Rd,The property is 1/2 mile down on the Left. PRIMARY CONTACT: Applicant SEWER TYPE: Septic Tank GALLONS PER DAY: 360 WATER SUPPLY: Public Water DESCRIBE WORK: IP for Subdividing* 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? No 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: New Structure STRUCTURE TYPE: PRIMARY RESIDENCE FACILITY TYPE: House OTHER DESCRIPTION: DESCRIPTION OF Vacant Lot EXISTING STRUCTURES ON SITE(IF ANY) DIM EXISTING STRUCTURE: NUMBER OF EXISTING BEDROOMS: #OF OCCUPANTS: 3 PROPOSED CONSTRUCTION NEW STRUCTURE DIM:: 50x30 #OF NEW BEDROOMS:: 3 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: P9-ehapplication 06/15/2016 15:31 Page I of4 s13• CATAWBA COUNTY Case# EHPR-06-2016-24110 Public Health Department Subdivision QJ• yC Environmental Health Division PIN# 279114441770 `'at• PO Box 389, 100-A Southwest Blvd,Newton.NC 28658 Ig.2 :. NAME ON PERMIT: (GEORGETTA LUCAS),2165 MOSS FARM RD,HICKORY NC 28602 ( Georgetta Lucas) Site Address: 2143 MOSS FARM RD, HICKORY NC 28602 Property Size: Square Feet 130,680.00 Acres 3.00 Directions: From Hwy 127 South, Right onto Moss Farm Rd,The property is 1/2 mile down on the Left. 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 accessibl sot t a complet -site ev luation can be performed. Date: n(ry/4/2o)(Fi Signature of Applicant or Agent -�nriv&`�/`? / An Environmental Health Specialist will contact you within 5 worki g( days of applicat o date. If you need further information or assistance please call 828-466-7291 AREA2 I agl @9hh 6' P Ins„- x'tr 111111' I I1 t'i, I 1 I IU1r9IIlllIPux�.;gm;Mk I tt .3 - PIaltiff ty ('1-I I,FEENAME!9'm i inttt" Il,lI�(, �I 1 rtr= IIIiI�1J�LaATE viil��I( FEEhA'MOUNTJ Improvement Permit Fee 06/15/2016 $150.00 f 1J1 'r TOTAJIFEEs 11 {1911i1'�1 `�� tIN 111#I�HflUINW.r., l lii,(I�IlIfi! el[siso oo �II uRI I I I i� I' a,1 Illi i mfr �. i c ��� i 1100,LWII Ittiill rilmit' IfI.;,NJi 9iRJr pc.l 11 UiiIiIIIilllr� i!d!BtLttitiotin Gi,3X"yjlllulllllnr`+.7fitriaipitro4,,14rr t 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-ehapplication 06/15/2016 15:31 Page 2 of 4 t�;�� \ 1!' THIS IS NOT A PERMIT ',f� ',�. CATAWBA COUNTY HEALTH DEPARTMENT counrn :� Page 1 ` Application for Environmental Services g - „onn��,a�� APP Improvement Permit Authorization to Construct❑ Septic Repair❑ Septic Malfunction n Septic Expansion ❑ New Well Permit I 1 Replacement Well ❑ Well Abandonment U Well Repair ❑ Existing System Inspection (Pre-Approval Required) ❑ Application iss foorr New Construction Existing Facility Property Address'Z� 7 l rain')m J Subdivision Lot# Acres Section/Block/Phase Driving Directions to Property . n C 2 o '41/Cy. `v` 0 ti a s o . r'Mt J- I- Z �' le_ n o - ' NAME TO APPEAR ON PERMIT? Rowmer ❑ Applicant LI Contractor Applicant Contact Information L Name Het yc0n I vurhbJ. q Address Pa. 3 nn 243 J Lvc kory , NC- fl a3 Phone ( kzs)32s-, 2 c I Cell Phone (g2s) 23,Frc 3F ce Owner Contact Information Name 6co(- .,�-�t�� Lucia_3 Address 2 Moss (ar,n 2c\, Phone (e 2_?-) . q . l i l y 1 Cell Phone Contractor Contact Information Name Address Phone I Cell Phone WHO WILL BE THE PRIMARY CONTACT? � /U Owner Applicant n Contractor (u l" LO , Description of Existing Structures on Site 1V' # of Bedrooms *j' Structure Dimensions #of Occupants Basement ❑ Yes ❑ No Basement Fixtures ® Yes * 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. 0 Yes CYNo Does the site contain any jurisdictional wetlands? El Yes 'To Does the site contain any existing wastewater systems? O Yes GYNo Is any wastewater going to be generated on the site other than domestic sewage? ® Yes GLNo Is the site subject to approval by any other public agency? O Yes lip/o Are there any easements or right of ways on this property? Describe Existing water supply in use ❑ individual Well n Community Well ❑ Semi-Public Well County/City/Township Water Line Is a public water supply available? ** [ es ❑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 EKAly (OArA co U]BA THIS IS NOT A PERMIT y N `�.-9' 1f.➢ CATAWBA COUNTY HEALTH DEPARTMENT Application for Environmental Services Page 2 Proposed Facility Type n Primary Residence %New Residence n Addition to Residence # of New Bedrooms 1. S Project Description .. 1-632 Structure Dimensions,qj' T^ ,-30 # of Occupants 3 Basement n Yes a No Basement Fixtures ® Yes ® No I Accessory Structure(s) Describe #of New Bedrooms *t if applicable Structure Dimensions # of Occupants Accessory Dwelling In Yes I I No Plumbing n Yes I No Describe Plumbing Needed I Multi-Family Residence# Units #Bedrooms per Unit*j' Total#Bedrooms *j' 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.) Fl 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 n Individual Well ❑ Semi-Public Well ❑ Community Well Abandonment Type ❑ Drilled ❑ Bored ❑ Dug ❑ 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. j 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. Date C>C> f5/ / Signature of Owner or Agent Printed Name of Owner or Agent p cleh s e . • Catawba County Environmental Health ------_________ \ \\\ •2245 40 4.09 t 250.e1` 0s a'r oe c t 450,• 1 2219 %! r „../ 4 !Vb1# 1 89 spX99.'. - j' \ ,: . i: . ` i 5"...., 54:, . .. .:. . . . , \1 a�< 'off .\ y<�': r OJ�� t ----\\ c\ 0 •5••3 \` u. . / pp\ at Parcel: 2791 1 4441 770, 2165 MOSS FARM RD 1 in=150ft HICKORY, 28602 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 06/15/2016 Parcel Report Page 1 of I Parcel Report - Catawba County NC Parcel Information: Owner Information: Parcel ID: 279114441770 Owner: LUCAS GEORGETTA M Parcel Address: 2165 MOSS FARM RD Owner2: null City: HICKORY, 28602 Address: 2165 MOSS FARM RD LRK(REID): 48202 Address2: null Deed Book/Page: 1892/0292 City: HICKORY Subdivision: null State/Zip: NC 28602-8312 Lots/Block: null/ null School Information: Last Sale: $100,000 on 1994-07-01 School District: COUNTY Plat Book/Page: Elementary School: MOUNTAIN VIEW Legal: null Middle School: JACOBS FORK Calculated Acreage: 7.230 Tax Map: 133H 01012 High School: FRED T FOARD Township: HICKORY School Map State Road #: 1194 TaxNalue Information: Tax Rates(pdf) Zoning Information: City Tax District: All in County Zoning District: COUNTY County Fire District: MOUNTAIN VIEW Zoningl: R-20 Building(s) Value: $128,500 Zoning2: null Land Value: $70,400 Zoning3: null Assessed Total Value: $198,900 Zoning Overlay: null Year Built/Remodeled: 1941/1997 Small Area: MOUNTAIN VIEW 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 #: 3710279100J Building Details 2010 Census Block: 2009 WaterShed: null 2010 Census Tract: 011101 Voter Precinct: P24 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. 21 u? 2 2 c 2 3 AeltS http://gis.catawbacountync.gov/nomap/parcel_report.php?key=279114441770&typ=P 6/15/2016 83A CATAWBA COUNTY H a .,l Y OG� ]ON, SOUTHWEST BLVD RECEIPT NEWTON,NORTH CAROLINA 28658 d crnxaaiiVe PHONE: 828.465.8399 U1 C Wednesday, June 15, 2016 / vdsv, 842 5M www.catawbacountync.gov PAYOR: Thornburg,Hayden PAYMENTS TRANSACTION NUMBER: TRC-692711-15-06-2016 PAYMENT DATE : 06/15/2016 PAYMENT TYPE: Check 1374 INVOICE NUMBER FEE NAME FEE AMOUNT 06-16-329488 Improvement Permit Fee $150.00 TOTAL PAYMENTS : $150.00 EHPR-06-2016-24110 CASE TYPE: Environmental Health Plan Review WORK CLASS: OSWP SITE ADDRESS: 2143 MOSS FARM RD, HICKORY NC 28602 Applicant HAYDEN THORNBURG, PO BOX 3443,HICKORY NC 28603 H:8283282936C:8282386398 **NO PEOPLESOFTACCOUNTASSIGNED ** Owner GEORGETTA LUCAS,2165 MOSS FARM RD, HICKORY NC 28602 receipt 06/15/2016 15:31 Page I of 1