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OPERATIONS PERMIT FOR 1Y~E IV WASTEWATER SYSTEM
PERMIT NUMBER
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In accordance with the provisions of Article 11 of Chapter
130A, General Statutes of North Carolina as amended, and other
applicable Laws and Rules
PERMISSION IS HEREBY GRANTED TO
Dean Warsham
CATAWBA COUNTY
FOR THE
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~peration of a wastewater collection, treatment, and disposal
sys.tem to se~ve, Tax Map Number 6AJ - 3 - 2 pursuant to 15 A NCAC
18A 1900 et seq and in conformity with the application,
improvement permit, and other supporting data subsequently ti1~p
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~a~g_:i:!,:pprOV~9. by the CataW0.rT(:!0unty Health Department and considered
a "'p'art:. of this permit
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Facilities to be served (Address and specific type of facility)
4030 Miller Drive
Hickory NC
Type 4A
The approved wastewater collection, treatment and disposal system
consists of
(1) 1000 gallon septic tank
(2) 1000 gallon pump tank
(3) Effluent Pump 43gpm 17tdh
(4) 8 lines 60 foot long
(5) Split fields
(6) 2 foot of head on upper lines
(7) 4 gate valves
The Owner shall be subject to all applicable provisions of Article
11 of Chapter 130A of the General Statutes and 15A NCAC 18A 1900
et seq The Owner is especially referred to Rules 1935(29,31),
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1937(d,e) ,
through d) ,
1938 (g), 1945 (a,b),
1965, 1967 and 1968
1950 (a through i),
1961(a
The Owner shall also be subject to the following specified
conditions and limitations as they apply
I GENERAL CONDITIONS
This permit is effective only witp respect to the number and type
of proposed facilities and volume and nature of wastes specified
In the event that the facilities fail to perform satisfactorily,
including the creation of nuisance conditions, the Owner/Operator
shall take immediate corrective actions to correct the problem,
including actions as may be required by the Catawba County Health
Dept , such as the construction of or replacement of wastewater
treatment or disposal facilities, upon receipt of a repair permit
The septage generated from this system shall be disposed of in
accordance with Article 9 of Chapter 130A of the General Statutes
and 15A NCAC 13B 0100 et seq and in a manner approved by the
North Carolina Division Of Solid Waste Management
The issuance of this permit shall not relieve the Owner of the
responsibility for damages to surface or groundwaters resulting
from the operation of this system Neither does the issuance of
this permit exempt the Owner from complying with any and all
statutes, rules, regulations, or ordinances which may be imposed by
other government agencies (local, state, and federal) which have
jurisdiction
This permit may become suspended or revoked if the soils fail to
adequately absorb and treat the wastes or if the facilities are not
maintained and operated as designed The system must be operated
and maintained in a manner which will not create a public health
hazard or nuisance by surfacing of effluent or discharge directly
into ground water or surface water any time during the operation of
the system
Adequate measures shall be taken to divert stormwater from the
disposal field area and to prevent wastewater runoff
Diversion or bypassing of the untreated wastewater from the
treatment facilities is prohibited
"
Prior to the transfer of this land to a new owner, a notice shall
be given to the new owner that gives full details about the system
and the materials applied or incorporated at this site At the
time of the sale of the property a new Operations Permit will have
to be issued Operations permits are nontransferable.
The designated repair area shall be reserved for the installation
of additional nitrification fields and is not to be covered with
structures or impervious materials
No addition, expansion, alteration or other repairs shall be made
to the wastewater system without first obtaining an improvement
permit from the Catawba County Health Dept in accordance with GS
130A-336
Failure to abide by the conditions and limitations contained in
this permit may subj ect the Owner to an enforcement action in
accordance with North Carolina General Statute 130A-18, 130A-22C,
130A-23, and/or 130A-25
In the event that the facilities fail to perform satisfactorily,
including the creation of nuisance conditions, the Owner/Operator
shall contact the Catawba County Environmental Health Section of
the Health Dept within 48 hrs of discovering this failure or
problem
A suitable cover, preferably fescue, shall be maintained over the
drainfields Grassed areas shall be kept mowed and the clippings
and other debris removed as needed to prevent thatch build-up No
traffic (including parking of RV's, boats, trailers as well as
other vehicles) or other equipment shall be allowed on the
drainfields with the exception of mowing equipment
Non-biodegradable products (plastics, metals, etc chemicals
(disinfectants, drain cleaners, acids, alkalies, pesticides,
petroleum products, etc ) or grease shall not be discharged into
the septic system
The owner shall keep the plumbing system in the facility in good
repair and eliminate leaks, drips, or excess flows as they are
found Use of ultra low fixtures and conservative water use
practices are recommened
II OPERATION AND MAINTENANCE REQUIREMENTS
The Owner shall maintain a contract with a subsurface sewage system
operator who is currently certified by the Water Pollution Control
System Operators Certification Commission to maintain this system
Verification of any changes to the contract currently on file shall
be submitted in writing to the Catawba County Health Dept This
system is required to be inspected by the certified operator at a
minimum frequency of two times per year or as otherwise specified
by the Catawba County Health Dept
The distribution device should
visit for proper operation
inspected and set properly at
be inspected during each maintenance
If needed the pressure should be
each maintenance visit
Low pressure lateral lines shall be purged of solids at least once
a year using potable water directly or added into the dosing tank
If the operator and the health dept determine purging is needed
more or less frequently, then a new schedule shall be implemented
Pressure on the distribution lines shall be checked and adjusted in
accordance to design pressures after each purging and at least
semi-annually
Pump drawdown level (between the on-float and the off-float),
approximate dosing volume, and pump delivery rate shall be measured
after each purging and at least semi-annually
The owner and operator shall be responsible for assuring any broken
pipe, lateral end caps or cleanouts are repaired within 48 hrs of
becoming aware of such a problem The condition of all pipework
shall be evaluated during each inspection
Surface and subsurface water shall be diverted away from the tanks
and drainfield Outlets on diversion ditches and tile drainage
tubes shall be kept open and free flowing
The septic tank shall be inspected at least annually for leakage,
blockage of influent/effluent lines, structural integrity,
condition of baffle and tee, condition of risers if present, scum
and solids level, and effluent clarity
Solids shall be removed from the entire tank before the solids
depth exceeds 1/3 of the liquid depth in the inlet compartment, and
is otherwise determined to be needed by the operator or the Health
Dept
The dosing tank shall be inspected semi -annually for leakage,
structural integrity, condition of risers, solids level and
effluent clarity Solids shall be removed from the dosing tank
when solids are removed from the septic tank or when the solid
level is up to the pump or siphon intake level Solids
accumulating on the pump or siphon and floats shall be removed by
hosing
Pumps and electrical controls shall be inspected at least semi-
annually for pump presence and proper automatic functioning The
floats / pipe / control valves / union / anti-siphon hole are in
proper working condition The control panel/electrical
connections are properly maintained and operational The
highwater alarm is present and operating properly
Siphons, when present, shall be inspected at least semi-annually to
verify proper automatic functioning, and the highwater alarm is
present and properly operating
III MONITORING AND REPORTING REOUIREMENTS
Any monitoring deemed necessary by the Catawba Co Health Dept to
insure the proper performance of the system shall be performed
A record shall also be maintained documenting each site visit by
the operator, including visual observations of all system
components, and all maintenance activities It is recommended that
the owner be offered a copy of each document for each visit
A monitoring report, including all required records, signed by the
operator, shall be submitted on or before the last day of the month
following each 12 month period after permit issuance to the
following address
Catawba County Environmental Health
Attn George Pendergrass
PO Box 389
Newton, NC 28658
Non-compliance notification The owner/operator shall report by
telephone to the Catawba Co Health Dept , Phone No 465-8270, as
soon as possible, but in no case more than 48 hrs upon finding the
system is malfunctioning by the
effluent, discharge directly into
water, or when repairs are needed
surfacihg or backing up of
the ground water or surface
THE ;...:iJ DAY OF A{;,)p/}/?if7Y7 192.J
PERMIT ISSUED THIS
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Owner Signature
CATAWBA CO HEALTH DEPT
ENVIRONM~~~ HEALTH SECT
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NOTICE
All type 3, 4, 5, and 6 sewage disposal systems require the owner of this property to
sign an operations permit before the completion permit will be released.
All type 4A through 5B sewage disposal systems require the owner of this property to
contract with a certified operator before the completion permit will be released
All type 5C through 6B sewage disposal systems require the owner of this property to
contract with a Public Management Entity before the completion permIt will be released.
The Catawba County Building Inspectors will not release final power to the
structure until our office releases the completion permit.
This permit you have been issued falls into the following category
TYPE 3 TYPE 4A - 5B ~ TYPE 5C - 6B
You will need to contact George Pendergrass of the Catawba County Environmental Health
Section for the requirements that must be met. Please call any Monday through Friday, 8
am - 9 am at 465 - 8272
I understand that my signature is only for verification that I have received and read this
notice
Sigmtu~ff} (J rJ.b--<YJ~CYY'
Date
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LOW PRESSURE PUMP DESIGN CRITERIA
1. Pump Tarik
A. Tank with a capacity oft60 0 gallons_
B. l'umptank shall have access manhole extending 6 inches above finished
grade.
C. Effluent pump capable of delivering 13 gallons per minute and 17 feet
total dynamic head.
D. Controls to consist of a high water alarm and Du.~ I on and., off floats.
High water alarm to be on s~parate electrical circuit. ,
,E. Float for high water alarm shall be set no more than ~ inches above higq.
water level of pump cycle. '
F. All electrical connections, alarms and pump controls, to be outside of the
pump chamber cp1d shall be installed in NEMA 4X enclosure ( or equivalent).
Connections from controls to tank shall. be in watertight, gastight '
conduit.
g. Drill small hole, 5/32 inch in supply line in pipe six, inches above off
control float.
1(. Do NbT install a check valve..
2. Distribution System
A. Absolutely no construction of system shall take place while soil is in a
wet condition.
B. Heavy vehicle, traffic is prohibited over system area prior to, during and
after installation.
C. 8 laterals off of distribution manifold. Laterals to be arranged
in ~ groups with ~ laterals in each group.
D. Each group of laterals to be preceded by a gate valve.
E. Laterals to be 1 1/ 4 inches diameter PVC, 160 psi and to be &; 0 feet long.
F. Laterals shall be installed level on contour of slope, on Sfoot centers
G. Laterals to be installed in trenches l~ inches wide and ~ inches deep
with ,~ inches of stone under and --L inch ( es) over laterals, 1 inches
total.
H. Undisturbed earthen dam shall be at the head of each lateral co "revent
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backflow into other lines.
I. Supply manifold shall be slightly higher than distribution manifold.
Supply line shail have clean outs at each end. '
J. Sup'ply line to be,;( inch diameter Sch. 40 I'Ve.
K. Distribution manifold to be,Le'-Je. \ and ~ inch diameter Sch.40 PVC.
L. Gate valves shall be protected in val,ve boxes.
M~ Stabiliiearea, with ,grass as soon as possible after completi9n of the
system.
'N. Drainage improvements shall. be made as necessary to (Ii vert surface and
subSurface wa~r around or away from entire system area.
o. Backfilling of'trenches shall, be done with light equipment.
P. Copy of permit shall be on job site during all phases of construction.
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A. Laterals are numbered with nlimber_ _ being- the h~ghest and _ the
lowest.
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. B.. Only the stand pipes '. for lines; \ 1 3; ,5 and -2 are needed the others
can be capped at ground level. . ,
c. Stand pipes are to have threaded caps.:
D. Stand pipes are to be sleeved with 6 inch diameter section ofSCh. 40 we
and capped for protection and access.
~. Stand p:Lpes on lines 1) ~. 5 ahd l can be cut and capped at ground
level once pressure is set. I .
F. Pr<:)perty owner should be provided with stand pipes and insttucte4 as to
how to check and set the pressure.
G. Property' owner to be instructed on how to flush the system. This should
be done twice a year.
Stand
Pipe
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PROJECT
COUNTY
REFERENCE NO
DATE
Warsham
Catawba
2162
09-30-1997
SUMMARY OF DESIGN
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,DESIGN FLOW
APPLICATION RATE
JOTAL AREA REQUIRED
TOTAL LATERAL LENGTH REQUIRED
TOTAL LATERAL LENGTH SPECIFIED
NQIViBER OF FIELDS
LATERAL LENGTH
NUMBER OF LATERALS
NUMBER OF LATERALS PER FIELD
SLOPE
NO 1
LATERAL PIPE SIZE
MANIFOLD PIPE SIZE
BUPPLY LINE PIPE SIZE
SqPPLYLINE, LENGTH
TOTAL DYNAMI~ HEAD
DOSING VOLUME
PUMP TANK INSIDE LENGTH
puMp TANK INSIDE WIDTH
PUMP TANK DRAWDOWN
360
o 15
2400
480
480
1
60
8
8
o
1 1/4
3
2
25
16 59
280
8 00.,
4 00
1 17
MINIMUM DOSING VOLUME
MAXIMUM DOSING 'VOLUME
SELECTED DOSING VOLUME
230 4 GALS
460 8 GALS
280 0 GALS
GPD
GPD/SQFT
SQFT
LFT
LFT
FT
PERCENT
PE}~OW PER:
/'
LATERAL
41
8 %
INCHES ( SDR 26 )
INCHES ( SDR 26 )
INCHE$ (SCHEDULE 4~)
FEET
FEET
GALLONS
FEET
FEET
FEET
(PUMP RUN TIME
(PUMP RUN TIME
(PUMP RUN TIME
5 2 MIN )
10 4 MIN }
6 3 MIN )
FIELD NO 1
LAT
NO
1
2
3
4
LENGTH ELEV-
ATION
60
60 ,
60
60
103 00
102 60
102 45
102 20
PRESS
HEAD
3 00
3 40
3 55
3 80
PRESS ANY KEY TO CONTINUE
HOLE
SIZE
o 156
o 156
o 156
o 156
~ ~
HOLE
SPAC
5 00
5 45
6' 00
6 67
L~~~
s'
NO OF FLOW PER FLOW PER FLOW PER
HOLES HOLE LATERAL LIN FT
12
11
10-
9
o 50
o 53
o 54
'0 56
FLOW TO FIELD
FLOW VARIATION
WOULD YOU LIKE A PRINTOUT OF THIS DESIGN ? (Y/N)
5 96 0 099
5 82 0 097
5 41 0 090
5 03 0 084'
'22 22 GPM
15 6 %'
FIEIJD NO, 1
~ HOtE
LAT LENGTH ELEV- PRESS HOLE NO OF FLOW PER FLOW PEB, FLOW PER
NO", AT ION HEAD SIZE SPAC HQLES HOLE LATERAL LIN -FT
1 60 103 05 3 00 0 156 5 4.5 11 0 50 5 47 0 091
2 ,60 102 50 3 55 0 156 6 00 10 0 54 5 41 0 090
3 60 102 20, '3 85 0 156 6 67 9 0 56 5 07 0 084
4 60 101 85 4 20 0 156 7 50 8 0 59 4 70 0 078
FLOW TO FIELD- 20 64 GPM
FLOW VARIATIQN 13 9 %
PRESS ANY KEY TO CONTINUE
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CATAWBA COUNTY HEALTH DEPARTMENT
Applicatio.p. f~r Improvement Permit or Authorization to Construct
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Property Owner !Ii ~ _~ ----.-----: _
Address
Name of Subdivision
Road Number/Name
DirectIOns to Property
Business Phone f3.0 [l -/75::,"\} ?
J.~b()3 Home Phone3 c:3 6 '"' J <;Suy L
Busmess Phone
Home Phone
Section/Block/Phase
3
4 Property Size Square Feet Acres 9 /.; 0 Date Platted/Recorded
5 TYPE OF FACILITY House Mobile Home /" Dimension of Structure .t.. r X f(' 0 Bedrooms 3
Basement. yes/no, Water Using Fixtures in Basement yes/no No in Family :5
.-r _
Hot Tub or Spa yes/~
MULTIPLE FAMILY RESIDENCE Units /,, /19 Total Number of Bedrooms /V>.Jj
DAY CARE Number of Children /V" /?
REST A URANT Seats ~Square Feet Dining Area4' /IT Square Feet Foodstandl.Meat Market Floor Space~ / h'
TYPE OF BUSI~ESS ,///" /" /f-" Number of Employees 1st A/}/ Jj- 2nd ~~~ 3rd '~h1.
OTHER. (SpeCIfy)
6 Do you anticipate any additions to Facility? yes/~
If so, describe
7 Has any gradmg, removal, or addItion of soil been done to this property? yes/no
-
If so, describ~
8 Are there easements/nght-of-ways recorded on this property? ~/no ,
9 Has thIS property been demed an Authonzation to Construct in the past? yes/no~t kno~
10 Type of Water Supply Individual Well Community Well V- Municipal
I understand that thIS is a formal application for an Improvement Permit or Authorization to Construct a ground absorption
sewage disposal system to serve the above described facility on this property and authorize Catawba County Health Department
employees to go on this property for evaluation purposes I certify the above inform<;ltion to be correct and understand that an
Improvement Permit Issued as a result of this mformation is transferable and has no expiration date, but may be revoked if this
informatIOn, site plans or intended use changes for the proposed facility An Authorization to Construct issued by this
department is valId for (5) five years from the date issued and is not transferable
Date 1)- '! -1? Signature of Owner or Agent C~ Q lA..-Jc7v1--ol~
********************************************************************************************************
(FOR OFFICE USE ONLY)
Improvement Permit Authorization to Construct
Please Contact .....00 ~ D ~tween 8 am and 9 am Phone
Zoning APproval:Q;)no Zoning Approval # 2.. <7 7 () b L/ / S Tax Map #
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Improvement Permit
Authonzation to Construct
RedeSIgn Fee
Retnp Fee
4' It) a
Date Paid
Date Paid
Date Paid
Date Paid
?-?~7
Receipt #
ReceIpt # CJ 5tJ [( 6J
Receipt #
Receipt #
Initial
Initial -z
Initial --~
Initial
****IF A PERMIT HAS TO BE REDESIGNED AND/OR RETRIPS MADE TO THE PROPERTY, THERE IS AN****
ADDITIONAL $25 CHARGE.
White Office
Yellow Owner/Agent
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11
TELEPHONE. 704-465-8270 TDD 704-465-8200
1
,
Complete all applicable blanks, mark N/A (not apphcable) in blanks which do not apply to your request An
evaluation will not be done until the applicatIOn is S,atlsfactorily completed
2
, ' ,
Include a copy of a scaled plat or GIS map of the property :Draw in the proposed locatIOn of the house,
mobile home or other structures, dnveways and dedicated right-of-ways (toads, electt'ical, phone, etc) Locate
the facility by showing specific setback dImensIons to the front, SIde and feat of residence when apphcable
Also show the location of existing wells. (and wells withh1i'100 feet of youfproperty) streams and lakes.
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Check with the appropriate Zoning Department to deterrrtiny' how your prQperty is zoned
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Once the applIcation has been satisfactorily completed, a plat or map of property haS-been irtcluded, and the
land has been prepared for evaluation, call the "Sanitarian to Contact" listed Oll the front of this application.
The-Sanitanan will place flags in the area for pr,oposed septic tank installation for soil test holes to be dug
Once the holes hav~ beeI1 dug, call the Sanita,rian again fpr the soils evaluatIOn
..
3
4
5
,
Evaluations wIll be completed as soon as possible after receipt ot application. Our department cannot
guarantee same day serVIce, but will operate on a first come service and work load pnority schedule
6
Do Not Grade or Fill Your Lot until the sanitarian has visited your proposed bujlding site and issued an
Improvement Permit or Authorization to Construct. Once the Improvement Permit or Authorization to
Construct has been issued, the ground over the proposed septic tank nitrification field and repair area
for the nitrification field should not be graded or filled. If this area is graded or filled, you may vo~d
your Improvement Permit Authorization to Construct. If the area is graded or filled before an
Improvement Permit is issued, you may not be issued an IlllprovementPermit or Authorization to
Construct. .~,
7
An Improvement Permit has ne expiration date"and is,transferable ;1S long as all site conditions and intended
uses do not change If changes do occur, the Improvement Permit is subject to revocation. A request for a lot
evaluation Does Not guarantee that an Improvement Permit or Authorization to Construct will be issued
8
Improvement Permits and Authorization to Construct may be changed only by Catawba County Hea,lth
I)epartment staff Any alterations or deviations from the Improvement Permit or Authorization to
,Constr~ct Jllay result in your Permit being voided by the Catawb~ County Health Department. Change~
in design or loc~tion will. require a new application; and fee. There will also be,a fee for re-trips.
9
All property lines must be clearly marked with stakes; string or flags
10
Stake the location of the house. mobile home or structures. including decks. porches. ~arages. as shown
on your plat
11
Clear bushes. large weeds. and briars from the area to be evaluated. DO NOT CUT LARGE TREES OR
GRADE TOP SOIL FROM THE LOT
12
-.
At flags placed by the Sanitarian, dig 48 inch deep holes for soil evaluation. The holes need tp jJe 12 inches in
dIameter or dug by a"backhoe \ \', " '\' \' ,:-
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13 Call the Sanitanan when the lot is ready for evaluation.
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14 " An Authorization to Construct wastewater system permit is valId for (5) five years
required to obtain a building permit.
.
. "
it IS not transferable and IS
15 ApplicatIOn void after 24 months
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NORTH
F'~ ,
Catawb'a' County, 'North Carolina
This map product was prepared frqm the Catawba County, NC, Geographic Information System
Catawba County ~as made substantial efforts to ensure the accuracy of location and labeling information
contained on this map, Catawbci' Qounty promotes and recommends the independent verification of any,
data contained on this map 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, ini:lirect Qr consequential which arises or may arise from this map product or the use thereof by
any person or entity
Scale 1 inch = 100 feet
Selected Parcel Number: 3608.04.94.7267
Prepared For Dean Warsham
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DATE: 07/09/97
PERMIT I Z9106415
(::~ I~~lt; If.'<ll~ll,.,,n':;it IP::llI rc:: (;ll U 1l''4l TV'
CERrXprCATe OF LON~NQ COMPLXANCE
RES1DLNT~AL PERM~T
Phone: (704) 466-8380
APPLICANT:
NAME
A()[)RE8S
WARSHAI't DEAN A
PO BOX 4315
PHONE
HICKORY. Ne 28603
704/395-H~4~?,
!
3608-04-94-7267.0000
6A,'J-3...,2
4030 MILLEH DR
118
LOCATIoN:
PIN NUMBER
TAX MAP PARCEL
E-911 ADDRESS
CENSUS TRACT
TYPE OF RESIDENCE: DDUBLEWIDE/MUlTI seCT.-CLASS A
INI"'OfH1A-nON:
tONING CLASSIFICATION!
'~~J.?:l~, OF LOT
HH' Yt:AH FLOOD PLAIN'.?
PROPERTY OWNtR5HIP
R-2
tOT
NO
PVT
SE:TRACKS
FHONT 30
SIDE 15
1~I:tAR :) 0
fEE'!
FEET
fEET
Before all lMpeetiQl1 CiiIl be mad~ by th? BIlUding Inspection 01f!()e, the applicant must pull a 'i~tijl9 to d\l$igllllh the sld1 and
rear pl'i)pfrty llot\1> \there the $tructure ill being placlJd or coo&tructcd.
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2, HQIII~.haH b~ plaQ~d 011 th~ lot in harlllony '11th the .itHuHt structures, or have the front ~u\1r hc~ the road fr~ntage.
3 AllllloMle hOOJ~s must Ita undmkirted before power eM &Q COllllect~d.
4. 0111y an~ l1loblle home shall Oil allQ\led pet' lot or p~ml of land.
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5. Ihl!ltRShilH hlwe !.lither dlll'K or pmh vith steps, located ill tho front Qf the home (minimum shl! ~hilll measure at least 36 sqUllrg f~{!tl
COJl'lfltEllns:
'fl /09/97
tPK - G,C. PAH~ l~r 2C
The applicant hilrilby certIfies that all informatiofl and atl;t\cblllents t\i tbtl'i CertH.\l;atlJ of Zoning tlUllpHam m true and cOtr@ct, qnd
11CKI1\I\lIl!dgt\s that thh v~rfllit \illS ie~t1ed 1111 tbe bads of tbe infQrlflilticrt ri'qlllred hmill.Fbe ilWlic311t turthel' acknQull!dges that any to!lstrtJc-til1n,
altt1l'atloll or ilGdition \micb IIHfm from thi$ i\~vHcat1~n shall ~ff s\lbj~tt tll relllllval !If dtflratlo!l $0 as to bring said ~tr\lctuH lllta conformance
\l1th tho tlledf1catiollS MO standard!J of the C~ta\Jba COllnty l!illlng Ur{lill8nco Such cormtlv'.i action sbaH bB at th~ expooM of the .~ppHcflllt.
It 1s the ri!~PQlIfllbIHty Ilj' IlppHcant tll CQUljlly \lith an ~dstil\g deild rostrldhlll$ plJftaillingb tho property IutM(lee of this ~jHmit is not
"'tlfi",U!' ,f ''''"opli,"" an' d." Joot "U." 'ppli",t.f tb, <luty t, ,,,,,,ly . q / a 1
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AP~"FrCANT' S S:J:6NATUlH? DATE '
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~INB APP ~ BV DATE