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Home My WebLink AboutEHPR-5-11-10923 (2).TIF .�$ THIS IS NOT A PERMIT Case # EHPR-5-11-10923 � � �' � CATAWBA COUNTY HEALTH DEPARTMENT v '.��a '�' Plan Review Application for Environmental Services 1g�}2 sM Environmental Health Plan Review - Septic Malfunction CP � REPLACE WELL - ABANDONMENT - SEPTIC MALFUNCTION ��h� AME ON PERMIT BOBBY DISHMAN SITE ADDRESS: 7248 LYNBROOK CREEK RD Denver, NC Pin#: 460605272868 NAME of SUBDIVISION: CRESCENT LAND AND TIMBER CORP Lot # 5'7 Section/Block/Phase PROPERTY SIZE: Square Feet Acres 0.769 DIRECTIONS: HWY 16 TURN LEFT ON CAMPGROUND RD TURN LEFT ON CATAWBA BURRIS TURN RIGHT ON BANK HEAD TURN LEFT ON WOODCHUCK GO TO STOP SIGN 7248 IS STRAIGHT AHEAD APPLICANT OWNER CONTRACTOR BOBBY DISHMAN BOBBY DISHMAN 3261 KERNERSVILLE RD 3261 KERNERSVILLE RD WINSTON-SALEM NC 27107 WINSTON-SALEM NC 27107 33fr971-9972 33fr971-9972 PRIMARY CONTACT: Applicant APPLICATION FOR: Existing Structure DIM EXISTING STRUCTURE: 28X54 EXISTING FACILITY TYPE: House NUMBER OF EXISTING BEDROOMS: � SEWER TYPE: Septic Tank NUMBER OF EXISTING OCCUPANTS: 6 EXISTING WATER SUPPLY IN USE: Private Well CALCULATED DESIGN FLOW: 600 Public water is **NOT'"* available for this property. PUBLIC WATER TYPE AVAILABLE: DESCRIBE WORK: SEWAGE SURFACiNG OUTSIDE DESCRIPTION OF HOUSE EXISTING STRUCTURES ON SITE (IF ANY) PROPERTY E A S EMENTS: NOE PROPOSED CONSTRUCTION APPLICATION FOR WELL CONSTRUCTION/ABANDONMENT/REPAIR PROPOSED WELL TYPE: ABANDONMENT TYPE: Unknown WELL REPAI REQUESTED? I understand that this is a formal application for a well permit, 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. 1 certify the above information to be correct and understand that an Improvement Permit issued as a result of this information is transferable and may be eligible for a norFexpiring date, but may be revoked if this information, site plans or intended use changes for the proposed facility. A Well Permit and Authorization to Construct issued by this department is valid for (5) five years from the date issued and is not transferable. Note: You must obtain Zoning Approval prior to locating a home or structure on this property. Any representation by you of house or struc re location should conform to applicable setbacks. Date: � I Signature of Applicant or Agent An Environmental Health Specialist will contact you with 2 working days of application date. If you need further information or assistance please call 828-466-7291 AREAl *******�*****�***********�************�****�******�*******�*******�************************�*�***************�******** Minimum SetbacKs Front: Side: Rear: Side St: Max Height: 06/13/11 16:34 � CATAWBA COi1NTY Case # EHPR-5-11-10923 G Public Health Department Subdivision ¢ � Environmental Health Division - Plan Review CRESCENT LAND AND TII� �''< PO Box 389, 100.A Southwest Blvd, Newton, NC 28658 Lo� 57 Ig 2 � P�# 460605272868 Applicant/Owner BOBBY DISHMAN, 3261 KERNERSVILLE RD, WINSTON-SALEM NC 27107 Site Address: 7248 LYNBROOK CREEK RD, Denver, NC Property Size: SF 0.769 ACRES Directions: HWY 16 TURN LEFT ON CAMPGROUND RD TURN LEFT ON CATAWBA BURRIS TURN RIGHT ON BANK HEAD TURN LEFT ON WOODCHUCK GO TO STOP SIGN 7248 IS STRAIGHT AHEAD FEE NAME DATE AMOUNT BALANCE DUE Authorization to Construct (Repair) Fee OS/17/2011 $425.00 $0.00 Well Permit & Inspection Fee 06/13/2011 $300.00 $0.00 TOTAL FEES $725.00 $0.00 CHANGE WORK ORDER REQUIRING REDESIGN AND/OR RETRIP WILL INCURE AN ADDITIONAL CHARGE (SEE FEE SCHEDULE) 06/13/11 16:34 .�� ep CATAWBA COUNTY, NC �,� �,� 100-A South West Blvd pLAN RECEIPT � � Newton, NC 28658- V �� (828)465-8399 Monday, June 13, 2011 �► 1$ [�Z sM www.catawbacountync.gov P�an �ase: EHPR-5-11-10923 �nvoice Number: INV-6-11-276327 Environmental Health Plan Review Invoice Date: 06/13/2011 Site Address: �248 LYNBROOK CREEK RD, Denver, NC APPLICANT OWNER CONTRACTOR BOBBY DISHMAN BOBBY DISHMAN 3261 KERNERSVILLE RD 3261 KERNERSVILLE RD WINSTON-SALEM NC 27107 WINSTON-SALEM NC 27107 33Er971-9972 336-971-9972 Fee Name Fee Amount Well Permit & Inspection Fee Fixed $300.00 Total Fees Due: $300.00 PAYMENTS PAYER: PATTY DISHMAN Date Pay Type Check Number Amount Paid ChangE 06/13/2011 Credit Card -1 $300.00 $0.00 Total Paid: $300.00 Total Due: $0.00 plan receipt 06/13/20ll 15:31 0h/10E'2F�11 13: �35' �357SSG�75� P�GE �1/�'� �-�:�::`�-�� T�IS IS NOT' �a E'�RMi"� �� , _'��. ��' 1,�zJ C,A�'.AWBA COUNTY HEA_i,T'H pEPARTM_ENT v��._ '� `;°-�;% Application for �n��ironmentad Services p l , - ��_:�r} �i,;, Improvement Pcrmit ❑ Authoriz�tiun to Cunstruct ❑ Septic RePnir � Septic Malfunction � � C, �'� Septic Fxpansion ❑ l�trw Well Perrz�it � Replacement tiVell � VVell Abaadanment � � �J� 7 Well Re air p ❑ E�isting S,ysteni �nspection (Pr�Approva! Required) ❑ Ap�lication ;s for New Constructxon ❑ F,sisiing .k'acilitS � I'roper Addrevs � � � L(,j��'�'�� , �� :�;ubdiv�sion �� . ,.'� �--.��._ �.ot # .. ,_ Acres _ �. , Section/�31oc1JPl�ASe Driving Di_rections ta Property � � �; `� ;,� �„� � L, i �� —.��- �� . <� f �� / r � _ — L . % r,� � �'e - � �c� r,-' � I V �l � j � q ; -.; � �. .�.� u I Q n, ; ; f /� � � . ^ � . - _ � �� • . ��-� �- . �"� � �_, � �� -..� � � � � � ; o � - � � �+ �� v!- 1 G r � V� C� c�-� C`�',.lC_. - L��S�.�L 1� F'� c � W -` �- �, �� t - �,�fi�... � t t� � �'.. v �� Q, NAML TO A.PPEAR N P.�R�-iIT? wner Applicant Contracror O Appl,cant Cox�cacr Inforrr�atiou V Na me ? � �, S' ✓r. G, G �,_: W Addmss �-• �''�' ��_—� � `.�',. .�.�-� 1� r-� � !r .S i ( 1 �� (L � '�; n ,!�z' �. �� .1 � I � � �-- � n � Phone - �e'S - � � �� Cell Phonc j � .��'� - � ��,�`� 7� Owner C ontact iri�orniatio � 1`�ame S ,.,� � � " .—� Z �lddress � O Phone Cefl Phone F` � . __I V Coutractor Contact Information W Name ' � rlddress � '� � � � Plionc Cell Pho.ne � ��IO �v�L� .RE TH� PK�n-�ARY CONTACT? �Owner [] llpplicant ❑ Contractor � � Desrription of E�;`isking 5tructures on Site � c� �<?.� Q � of Bedrooms ` j � 5ti Dimensions # of necunants �- � Dasement [�Ycs ❑ No Basement Fixhires Yes ❑ No J � Planned Puture Additions or Improvements (Building Pern�it NUT requested at this timej O Describe _ � � Proposed Future Structure Dimensions # ofBedreioms �Y if'applicable � Are there easemCnts or ri�ht-of-w recc�rded on lhis property ❑ Yes No Describe Is a public �ti su�piy available on or aclj��ccnt to the above property *�' ❑ Yes No Check i�-pe available ❑ C�nimunity Well ❑ Semi-Public W'ell ❑ County/City/Township Water Linc Existing water supply in use Jc�dividual 1�Vel( � COfIlI11lll11tV WCIl Semi-Public Well ❑ County/City/Totivnship �L'ater Line ❑�'�'�OU1.�D .�.�K� TO SCIIEDULE A CQMEt1t��D ]F'LAGGING AND SOIL FVA_i,UAT�ON ,,, (S�E COMBINED EVALUAT�ON �ROCEDUES) FJS;' ��''�F�11 13: �5' ,3"�5788�75� P�GE F32,f F�2 � i��: ,,,,- � ;� "I'H7S IS NUT A P.�R1��iT �.-'? � ,.r,r; �%` "�=; 'CATAW�3A COIJNTY HEALTH DEPARTN.[ENT �`"� J � �1pPlication for �nvirrniniental Services Page � � .r� ' . "�.!�� 4_ Propo�ed Facility Type U Primary Residence ❑ New Residence. [] Addition to Residence #� of Ne�v Beclrooms *7 Pxoje�ct llescription ""— Structure llimensions # of Occupants y f3ascment ❑ Yes ❑ T�TO Basernent Fi�'rures ❑ Yes ❑ No Accessory Structure(s) Describe # of New Bedroom5 '"�f if appJicable Structt,r.e Dimensions '� of Oeeup�,nts <�ccessory p�-ellin� � yes ❑ ;•lo Plumbing ❑ Yes ❑ No C�escribe Plumbing Needed ❑ Malti-Fantily Residcuce # Units _ #F3cdrooms per Uiiit'�1 ._ Total � �edrooms * f Struct«re T�imensi�ns [� Fond Service Specify Type # Seats �_ _ Floor Space -Entire T'oocl �ervice Pacility (Sq Pt1 f# Em�loyees per Shi.$ _ # of Shifts Dinin� Area (Sq. Ft. j�_ _ �usiness Sptcific TVpe Uf Business _ f�Ptail Floor $�ace # of Fmployees per Shift _, i� of Shifts Othcr Facility Type 9pecify i _ If Chutch � of Sest� _ Kitchen ❑�'es ❑ No If paycare Speci OccuPancy Application for Well Coastructiun/AbandonmentlRepair Proposed Well Type [� individ.ual Well ❑ Semi-Public Well ❑ Communie; ��'ell ,�bandonment Type ❑ Drilled ❑ Bored ❑ i�ug ❑ Unknoxm Wel l Repair Requested ❑ Yes ❑ No Describe Catci.tla.ted Desi� Flo�v, Commercial '� _ __ Additional inf'ormatioa ma}• be required fo detcr►nine design fio�• frum certain facilifies. This vulue will be determined during consultation ��th ou- site stAff. *Any room that wi.11 be intended fi�r sleepin� at khe iime af construrtion ar for fuhire consideration should be noted as a. bedroom and counted on all applications. The number of bedrooms will he confirmcd by rooms identified on house plans as a bedroom at the time of building pczmit i,s,unncc. This may prcvcnt the need f�r scptic system sizc increase +n ttie future, j�Tf structure is plumbed but no brdrooms� calculate;d desigrt flow is required. "* if No, a w�ell pern�it must bc issucd with t}ie Authorizatio.p i0 CUnstrucL Note: You must obtain Zonin¢ approval pnor i� locating a home or structu�e on this property. Any r��presentation b}� you of housc or structure location should cunfoTm to lpplicuble setbacks. 4 CHANGE WORK ORDER REQUIRiNG REDESIGN AND/OR RET.RIF WiLL TNCLtRE AN W ADDITiONAL CHARGE (SEE FE� SC.HEDULE) Q 1 understand tl�at tbis is a formal application for Environmental Sen-ices and sut}�orize Cata�•ba Co�u�ty Em�irc�nmental � He41th eniployccs tn gc� on this property fc,r cvalu.vti�n purposes. I cE-rtify the above infvrmation to be correct and undeTStand (� that an Improvement Permit issued as a re5ult �f tivs informution is valid for 5 ycar5 or may be non undcr ccrtain '�•► specified conditions. Improvemeiit Prm�its und R'ell �znnits are transf°rrable, but may be revol:ed if this informanon, site � W plans o.r intendec] use changes for the proposed facility. An nut.horization to Construct issued by this departrnent is valid for (:i) fvc ycars from the date issucd and i� ot transferabia j Si��lature of Orvner or Agent � ��7 , � �, �� Printed Nam� of Owner or Agent �, � �,,� �,�� Datc �o—�� -� , CATAWBA COUNTY ( � � 5 : � � '"�`'� Case # W LS2008-00167 � � !�� \ Public Health Uepartment ('< - ) Enviruntnental Health Division Subdivision , 9 �: \ � i / PO Box 38�, t00-A Southwest f3h�d. Newton. NC 286�8 SecdBUPh/Lo[ # 57 � �_i i ��. (823) 4G�-327U FAX (828) dG5-8276 TDD (828) d6�-3?00 PIN# 46060�272868 Applicant /Owner: BOBBY DISHMAN Site Address: 72�18 LYNBROOK CREEK RD DENVER 1VC �QS�cd SG Property size: SF .77 ACRES Directions: 16S/ LEFT CAMPGROUND RD/ LEFT CATAWBA BURRIS / RT BANKHEAD/ LEFT WOODCHUCK/ GO TO STOP SIGN / HOUSE ACROSS RD/ 1 1/2 STORY DWELLING/ CREME COLOR WELL PERMIT ProQosed Use: Private " Public Semi Other GROUTING DEPTH: MINIMUM 20 FEET SETBACKS: .,�- 1. BUILDNG FOUNDATIONS 2� FT. 5. UNDERGROUND STORAGE TANKS 100 Fi'. � 2. E;CISTING Rc PROPOSED SENTIC SYSTEMS - MIN. 50 Fi'. G. STkEAMS/13ROOKS/CREEKS �0 F1'. 3. EXISTING & PROPOSED SEPTIC REPAIR AREA - M W. �0 FI'. 7. LAKES/PONDS RESERVOIRS �0 FT. �� 4. SEWAGE PUMP SUPPLY LINE 50 FT. � ALL OTHER POSS[BLE SOUKCES OF GROUND �VATER CONTANIINA'1'ION 100 FT. The well driller must verify all sepearations �re uJhemd to before drillins the ��ell. If the �vell drilter is unable to maintain any ot the above separations. contact the Hcalth Depar[ment at (328) d6�-8270 beFore drilfin� the well. SEE SITE PLAN FOR PERMITTED WELL LOCATION ,�,z,,,,� ��,,,� 2/25/c�1� Issued Bv: Permit lssuance Date: 7 � ( �� '%��' '�� Customer Signature: WELL INSPECTION: GROUTED DEPTH: 20' � DATE: 3'�'S��$ INITIALS: S�� APPROVED CASING: PVC STEEL ✓ DATE: 3'�S IMTIALS: �S� CASING HEIGHT 12" ABOVE LAND SURFACE 7 � DATE: S 9 INITIALS: S� WELL COMPLETION REPORT RECEIVED DATE: S`f S`C�S INITIALS: �_ WELL HEAD APPROVED T DATE: _`I� INITIALS: $(� � nl .i �Y1 L � � � � � ' � � Well riller Date Drilled Well permits are valid for 5 years from the date of issuance and are subject to suspension and/or revocation fro non-compliance with appropriate state nnd local rules and regulations, or if fa(se information was �iven in order to obtain a permit. Wells shall be constructed in accordance with all state and local regulations and rules. The Well Completion Report must be submitted to the Health Department within 30 days upon completion of a well. (��,� 5 '(S C�� Authorized State Agent Final Approval Date Form D r.\7"idenuvAlFnrm.�vLS��un. rni ,i� �� ; cnT��wB� cou�rTY . ��, �� • � Case # �VLS2008-00167 � i�„ ;�� \ Public Hcalth Department �'< � � Environmental Health Division Subdivi5ion 4 SecUBUPh/C,ot #� \��. 'j��'� �PO Box 339. 100-A Southwest Bh�d, Newton, NC 23G�8 57 ��., �/ (828) 465-8270 FAX (828) dG5-8276 TDD (8?3) 4G�-8200 PIN# 460605272868 ApplicanUOwner BOBBY DISHMAN Site Address: 7248 LYNBROOK CREEK RD DENVER NC Property Si SF .77 ACRES Directions: 16S/ LEFT CAMPGROUND RD/ LEFT CATAW BA BURRIS / RT BANKHEAD/ LEFT WOODCHUCK! GO TO STOP SIGN / HOUSE ACROSS RD/ 1 1/2 STORY DWELLING/ CREME COLOR � Improvement Permit � Authorization To Construct � Well Permit SITE PLAN � �t,'ell w��-� Ix C l eus-�: -1C�` -�m � � �� — :Zs ` -�.� s�,-�. ��i-v � _ c)� ,.�,,�„ erUPei �in�S h �� Z�1. �1 ► � ��V h �� , � Z � ,� � � �;i ��°� , - �" J c `' J :a � � �- �� L ` ��, �� 7 o- _s . O � v o.ti` � -' ��. y5 � � = �1V� Scale System components represent approximate contours only. The contractor must flag the system prior to beginning the installation to ensure that proper grade is maintained. Do not install system under wet conditions. This permit is subject ot revocation if the site plan or site conditions are altered. �� , 2/25/UB Authorized State Agent Date Form C r:\T'ulemnrllPormNlVfSrma mr Catawba County, North ,Carolina, Disbursement Voucher ' � Fiscal Year 2010-11 Vendor No. Date 06/13/11 Bobby Dishman ,��p' C'' Voucher No(s). 3261 Kernersville Rd ��' �,� Winston Salem, NC 27107 ,� U ' d� � I842 DESCRIPTION AMOUNT EHPR5-11-10923 $150.00 Application revised to 3BR system refund difference SUB-TOTAL $150.00 SALES TAX FREGHT TOTAL $150.00 Fund Cost Center �� Object . Project Amount For Accounting� Use Only TOTAL $0.00 The undersigned hereby certifies that the goods or services specified above have been received or performed. Payment has not be previously authorized and this expenditure is a proper charge to the appropriation indicated. The above charge is certified to you for payment. (Signature - Appropriate Official) (Signature - Appropriate Official) � �� o � �� CATAWBA COUNTY v '�►` '`� P O Box 389 - Newton, North Carolina 28658 -(828) 465-8270 - F� (828) 465-8276 - TDD (828) 465-8200 �S 2 SM Public Health — Environmental Health Division AUTHORIZATION OF REFUND Date � � J 1 Case # �I�" �� -��11- jC��3 Applicant I��U�c ,� � � Refund Amount �/ � Refund Reason � 1C� ;� �'��'�C e>'�'l �,�� fb �,� , ,�t� C��v►�'c��C Authorizing Signature Received By Permit Center Staff �w >� �. ;' L" Date ��t3Ci f .�$ �'p CATAWBA COUNTY, NC �,� ��, 100-A South West Blvd pLAN RECEIPT � i--] Newton, NC 28658- U � � � (828)465-8399 Monday, June 13, 2011 �► j$ t�'1, sM www.catawbacountync.gov P�an �ase: EHPR-5-11-10923 �nvoice Number: INV-5-11-275415 Environmental Health Plan Review Invoice Date: 05/17/2011 Site Address: '7248 LYNBROOK CREEK RD, Denver, NC APPLICANT OWNER CONTRACTOR BOBBY DISHMAN BOBBY DISHMAN 3261 KERNERSVILLE RD 3261 KERNERSVILLE RD WINSTON-SALEM NC 27107 WINSTON-SALEM NC 27107 336-971-9972 33Er971-9972 Fee Name Fee Amount Authorization to Construct (Repair) Fee Adjustable $425.00 Total Fees Due: $425.00 PAYMENTS PAYER: BOBBY DISHMAN Date Pay Type Check Number Amount Paid Change 05/17/2011 Check 8764 $425.00 $0.00 06/13/2011 Refund -1 ($125.00) $0.00 Total Paid: $300.00 Total Due: $0.00 plan receipt 06/13/2011 16:34