HomeMy WebLinkAboutIMPV-08-2023-202451.tif •
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1i Public Health Department Sulxtivision
lot . Is' Environmental Health Division PIN% 266801485389
lilt./ PO Box 389.25 Government Drive,Newton.NC 28658 1 r}ro
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Site Address: 8765 JACOB FORK RIVER RD,VALE NC 28168
Name on Permit ADAM DYMORA
Property Size: Acres 34.05
Directions: Hwy 18 to Jacob Fork River Rd,Property is on the Right,Approx. 1 mile form Hwy 18(white fence/black)
Owner/Authorized Representative Acknowledgement of Permit Receipt
r v'P I certify that I um the owner or authorized agent(owner's authorization rcquircd)representing the owner of
the property described above.
As the property owner or authorized representative,I have received the above referenced
permit(s)as requested in the application for service itBI'K-07-2023-44950, by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
7 Electronic Image Transmittal/E-mail (Return receipt required)
I" 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 18A.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:08/11/2023
Owner/Authorized Representative Signature
Date 10 /g—she-n
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by _ (name of person sending permit)
(Aire
Signature �____ _____.____Date/'fime_�Q1� �3
1
Method: Fax 'Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
We wantt tto hear from yor,Please ttake a few momentts tto complette our custtomer service survey att
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$ CATAWBA COUNTY Case# IMPV-08-2023-202451
Public Health Department Subdivision
Environmental Health Division PIN# 266801485389
PO Box 389.25 Government Drive,Newton,NC 28658 LOT#
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Site Address: 8765 JACOB FORK RIVER RD,VALE NC 28168
Name on Permit: ADAM DYMORA
Property Size: Acres 34.05
Directions: Hwy 18 to Jacob Fork River Rd, Property is on the Right,Approx. 1 mile form Hwy 18(white fence/black)
Improvement Permit
AN AUTHORIZATION TO CONSTRUCT MUST BE ISSUED PRIOR TO BUILDING PERMITS
THIS PERMIT IS NOT FOR SEPTIC INSTALLATION
Permit Category: New Septic
Wastewater Flow 360 g.p.d
Type of Facility: Primary Residence-New house
Basement? No Basement Plumbing? No Bedrooms: 3
Water Supply: Private Well Maximum Occupants: 6
INITIAL SYSTEM SPECIFICATIONS
Proposed Wastewater System: 25%REDUCTION
System Classification: IIIG-OTHER NON-CONY TRENCH SYSTEMS
REPAIR SYSTEM SPECIFICATIONS
Repair System Required? Required
Proposed Wastewater System: 50%REDUCTION HORIZONTAL
System Classification: IIIE-PPBPS GRAVITY DOSED SYSTEM
Pump Required
Permit Conditions: *IMPV-07-2022-176448 was previously issued for this facility; however,the house box was
moved. This IP utilizes the same soils data from the previous IP and also stays
approximately within the same initial and repair area footprint.
Landscaping or other site alterations that potentially divert groundwater or surface water toward the septic system, or prevent proper
drainage away from the septic system, including the direction of gutter flows or foundation drains,is not approved,and may result in failure to
approve the initial system installation,or the suspension/revocation of existing permits.
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' (I5A NCAC 18A.1900). Neither Catawba County nor the Environmental Health
Specialist warrants that the septic tank system will continue to function satisfactorily for any given period of time.
Any permit issued for a conventional system may be used for an accepted system without Environmental Health authorization or permit
modification.Please notify Environmental Health of this change prior to system installation.
41& flAZ-101'nee Pe.kins
09/26/2023
Authorized State Agent Permit Issuance Date
9/26/2028
Permit Expiration Date
No grading or construction activity is allowed in areas designated for system and repair without approval of the Health Department.
10/11/2023 09:47
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