HomeMy WebLinkAboutIMPV-3-10-5619.TIF
~A CATAINBA COUNTY Case # IMPV-3-10-5619
Q Pudic Healrb DepaYtment Subdivision
Environmental Health Division
J d:~ PO Box 389, 100-A Southwest Blvd, Newton, NC 28658 Lot # A
1842 u PIN# 26680 1 1 78426
ApplicantlOwner CARL (RICK) ADAMS
Site Address: 9048 JACOB FORK RIVER RD, Vale, NC
Property Size: SF 0.759 ACRES
Directions: 1 OW / RT PROVIDENCE, CHURCH RD / LEFT OLD SHELBY RD / RT JACOB FORK RIVER RD / 1-1/2 MILES CROSS
SMALL BRIDGE / 1 ST DR ON RIGHT(go to drive at mailbox 9048, all way to end)
Improvement Permit
Permit Valid: Expires In Five Years: _X_ No Expiration:
Facility: House
Permit Category: Other Bedrooms 3 t ` ,
Projected Daily Flow 360 g.p.d "li
WATER SUPPLY: Well Type: Individual Well C~j
Basement? Yes Basement Plumbing? Yes
Proposed Wastewater System: CONVENTIONAL
Type: IIB - CONV SYSTEM WITH <750 LINEAR FEET OF LINE
Proposed Repair: 25% REDUCTION
Pump Required?: No
Operator Required?: NO
Permit Conditions: As built for existing system. IP for pool house.
The issuance of this permit by the Health Department does not guarantee the issuance of other permits. It is the responsibility of the
applicant/property owner to insure that all Catawba County Planning/Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes, or if site conditions are altered. The
Improvement Permit is not affected by a change in ownership of the property. This permit was issued in compliance with the
provisions of the North Carolina 'Laws and Rules for Sewage Treatment and Disposal Systems' (15A NCAC 18A .1900). Neither
Catawba County nor the Environmental Health Specialist warrants that the septic tank system will continue to function satisfactorily
Susan Bumgarner 03/19/2010
AUTHORIZED STATE AGENT APPROVAL DATE
Permit Expiration Date: 03/19/2015
No grading or construction activity is allowed in areas designated for system and repair without approval of the Health Department.
03/22/10 11:52
MAR-22-2010 11:29 CATAWBA COUNTY 1 828 465 8962 P.001
CARE (RICK) ADAMS
9048 JACOB FORK RIVER RD, VALE, NC
Owner/Authorized Representative Acknowledgement of Permit Receipt
_ I certify that I am the owner or authorized agent (owner's authorization required) representing the owner of
the property described above.
~.VAs the property owner or authorized representative, I have received the above referenced permit(s)
as requested in the application for service EHPR-3-1.0-4253 by the following method(s):
0_ Received in Person
_ Facsimile Transmittal (Return form with signature required)
Electronic Image Transmittal/ E-mail (Return receipt required)
W -As the property owner or authorized representative I have reviewed and understand the specific
conditions of the permit issued, and further understand that all applicable regulatory requirements
specified under the North Carolina Laws and Rules for Sewage Treatment and Disposal Systems
(15A NCAC 1$A.1900), and/or well Construction Standards (15A NCAC 2C.0100), shall apply to
the issuance of this permit and the construction of the wastewater system and/or water supply well
permitted.
Permit Issue Date 3/19/2010
Owner/Authorized Representative Signature
Date 3 ?Z- IO
- - - - - - -
Documentation of Permit(s) Transmittal
(hermit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature Date/'r'ime
Method: Fax Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
acknowledges the conditions and statements above.