HomeMy WebLinkAboutIMPV-4-11-17238.TIF � CATAWBA COiJNTY Case # IMPV-4-11-17238
G Public Health Department Subdivision
Q 2 CARL C& PAULA T LONG,
� Environmental Health Division
"�' PO Box 389, 100.A Southwest Blvd, Newton, NC 286�8 Lot # 1
!g 2 5M P1N# 3657029�9061
Applicant/owner CRYSTAL STALLINGS
Site Address: 3780 DAVIS RD, Maiden, NC
Property Size: SF 1.029 ACRES
Directions: HIGHWAY 16 S- TURN RIGHT ONTO BUFFALO SHOALS RD - GO PAST OLIVERS CROSSROAD - 2ND PAVED ST
TO RIGHT (DAVIS RD)
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.
_ As the property owner or authorized representative, I have received the above referenced permit(s) as
requested in the application for service EHPR-4-11-10231 , by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
_ Electronic Image Transmittal/ E-mail (Return receipt required)
_ 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), andlor 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: 04/21/2011
Owner/Authorized Representative Signature
Date
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Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature Date/Time
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.
04/21/11 10:36
� CATAWBA COUNTY Case # IMPV-4-11-17238
Public Health Department
Q , Subdivision CARL C& PAULA T LONG,
y Environmental Health Division
'�' PO Box 389, 100-A Southwest Blvd, Newton, NC 28658 Lot # 1
18 2 �M PIN# 3657029�9061
Applicant/Owner CRYSTAL STALLINGS
Site Address: 3780 DAVIS RD, Maiden, NC
Property Size: SF 1.029 ACRES
Directions: HIGHWAY 16 S- TURN RIGHT ONTO BUFFALO SHOALS RD - GO PAST OLIVERS CROSSROAD - 2ND PAVED ST
TO RIGHT (DAVIS RD)
Improvement Permit
INITIAL SYSTEM EXISTING - IP FOR REPAIR SYSTEM ONLY
Faci�ity: primary Residence 3 Bedroom House
Permit Category: Other Bedrooms 3
WATER SUPPLY: Private Well
Basement? Basement Plumbing?
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
INITIAL SYSTEM SPECIFICATIONS
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Permit Valid: Expires In Five Years: X_ No Expiration:
Projected Daily Flow 360 9•P•d
Proposed Wastewater System:
Type: IIIG - OTHER NON-CONV TRENCH SYSTEMS
Permit Conditions:
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
REPAIR SYSTEM SPECIFICATIONS
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Repair System Required? Required
Proposed Wastewater System: 25% RE D U CTION
Type: IIIG - OTHER NON-CONV TRENCH SYSTEMS
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
applicanUproperty 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 SewaPe Treatment and Disposal Svstems' (15A NCAC 18A 1900). Neither
Catawba County nor the Environmental Health Specialist warrants that the septic tank system will continue to function satisfactorily
Robbie Phelps 04/21/2011
AUTHORIZED STATE AGENT APPROVAL DATE
Permit Expiration Date: 04/19/2016
No grading or construction activity is allowed in areas designated for system and repair without approval of the Health Department.
04/21/11 10:36
�� CATAWBA COUNTY Permit # IMPV-4-11-17238
�+ G Name C stal Stallings
F., 'Z Public Health Department Address 3780 Davis Rd
L � � Environmental Health Division
v � PO Box 389, 100A Southwest Blvd, Newton NC 28658 P � #
I$ [J SM (828) 465-8270 Fas (828) 465-8276 TDD (828) 465-8200
SITE PLAN
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