IPAC-REPAIRHTE# Zr--g ca , Cl�
ISSUED TO:
NEW ❑ REPAIR ❑
Type of Structure:
Proposed Wastewater System Type:
Projected Daily Flow.
Number of bedrooms:
Basement ❑Yes ❑ No
Pump Required: []Yes ❑ No
Type of Water Supply: ❑ Community
Permit conditions:
Harnett County Department of Public Health
Improvement Permit
A building permit cannot be issued with only an Improvement Permit
PROPERTY LOCATION:
SUBDIVISION
EXPANSION ❑
GPD
Number of Occupants: max
29513
LOT #
Site Improvements required prior to Construction Authorization Issuance:
❑ May be required based on final location and elevations of facilities
❑ Public ❑ Well Distance from well feet
Permit valid for.
❑ Five years
❑ No expiration
— .... I"" "w" .5`r • Date: SEE ATTACHED SITE SKETCH
The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. This
site is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit shall not be affected by a change in ownership of the site. This permit is subject to compliance with the provisions of
the Laws and Rules for Sewage Treatment and Disposal and to conditions of this permit.
Construction Authorization
(Required for Building Permit
The construction and installation requirements of Rules .1950, .1951, .1954, .1955, .1956, .1957, .1958. and .1959 are incorporated by references were this permit and shall be met Systems shall be installed in accordance
with the attached system layout.
ISSUED TO: SArvuGt_ PROPERTY LOCATION: 'ASO GgsAN �GEc
SUBDIVISION LOT #
Facility Type: S O ❑ New ❑ Expansion ),S( Repair
Basement? ❑ Yes '*� No Basement Fixtures? ❑ Yes No
Type of Wastewater System" Qv m P `To e= �`� o Q o � s a o S )3—G.. (Initial) Wastewater Flow: 36 O GPD
(See note below, if applicable ❑)
InIitallation Requirements/Conditions
Septic Tank Size Gres,.+ G gallons
Pump Tank Size 1060 gallons
Pump Requirements: R TDM vs.
Conditions:
Number of trenches 1
Exact length of each trench 2.60 feet
Trenches shall be installed on contour at a
Maximum Trench Depth oh 1100 inches
(Trench bottoms shall be level to +/•1/4"
in all directions)
GPM
Trench Spacing: 9 Feet on Center
Soil Cover, —G ---Inches
(Maximum soil cover shall not exceed
36' above the trench bottom)
Aggregate Depth:
WATER LINES (INCLUDING IRRIGATION) MUST BE IOFT. FROM ANY PART OF SEPTIC SYSTEM OR REPAIR AREA.
NO UTILITIES ALLOWED IN INITIAL OR REPAIR DRAIN FIELD AREA.
inches below pipe
inches above pipe
inches total
**II applicable: / undeatand the fydYem type rpealed Lr different from the type tper&ed on the app/irr6on. / arrept the rperilratienr of this permit.
Date:
This Construction Authorization is subject m revocationa site plan, plat or the intended use changes. The construction Authorization shall not be transferred when there is a change in ownership of the site. This
Construction Authorization is jgct to mmpha ith the props f the Laws and Rules for Sewage Treatment and Disposal d m the conditions of this Permit, SEE ATTACHED SITE SKETCH
Authorized State Agent:
Date: 5
Construction Authorization Expiration Date: ' 5
HTE# REpc�Q—
Permit #
Harnett County Department of ll�iblic Health
Site 'ketch
PROPERTY LOCATON:_ S O �B ti C -n r r-- L,,3
ISSUED T0: a SUBDIVISION LOT #
Authorized State Agent: T Date: S g I 1
;�SL Gor,:n-PALM i0
ON S i'SG PQ.10(Z
,Na��� D��r`1 F,6r✓9
1,. 4113
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
307 W. CORNELIUS HARNETT BLVD.
LILLINGTON, NC 27546 4IOd
3 910-893-7547 PHONE !J
91
0-893-9371 FAX
W -u Application for Repairs
` T� 5e s� /o�-i c✓ uv,
EMAIL ADDRESS:
'HONE NUMBER_ 11 r / /k/ A
Yt - Cnrn /Oc,
� T-
PHYSICAL
MAILING ADDRESS (IF DIFFFERENT THAN PHYSICAL)
IF RENTING, LEASING, ETC., LIST PROPERTY OWNER
SUBDIVISION NAME
Type of Dwelling: [ ] Modular
Number of bedrooms
Garage: Yes [ ] No [ ]
Water Supply: [ ] Private Well
LOT #/TRACT# STATE RD/HWY
[ ] Mobile Home
[ ] Basement
Directions from Lillington to your site:
[ ] Stick built [ ]
Dishwasher: Yes [ ] No [ ]
[ ] Community System [ ] County
SIZE OF LOT/TRACT
Garbage Disposal: Yes [ ] No [ ]
In order for Environmental Health to help you with your repair, you will need to comply by completing the following:
1. A "surveyed and recorded man" and "deed to Your Property" must be attached to this application. Please inform us of any
wells on the property by showing on your survey map.
2. The outlet end of the tank and the distribution box will need to be uncovered and property lines flagged. After the tank is
uncovered, property lines flagged, underground utilities marked, and the orange sign has been placed, you will need to call
us at 910-893-7547 to confirm that your site is ready for evaluation.
Your system must be repaired within 30 days of issuance of the Improvement Permit or the time set within receipt of a violation
letter. (Whichever is applicable.)
By signing below, I certify that all of the above information is correct to the best of my knowledge. False information will result in
the denial of the permit. The permit is subject to revocation if the site plan, intended use, or ownership changes.
a�gnaaure
Date
Initial Application Date: -i j o I
Application# 17-201+1133
CU#
COUNTY OF HARNETT RESIDENTIAL LAND USE APPLICATION
Central Permitting 108 E. Front Street, Lillington, NC 27546 Phone: (910) 893-7525 ext:2 Fax: (910) 893-2793
www.hamett.org/pemils
"A RECORDED SURVEY MAP, RECORDED DEED (OR OFFER TO PURCHASE) 8 SITE PUN ARE REQUIRED WHEN SUBBMI IIING A�LAND USE APPLICATION -
LANDOWNER Jn... v e geA C Mailing Address: �J d Caw pr'Vl ( z1k L -w c
City. GAN'tr/O/I State:kZip2jMContact No: ZSS-(a9/-6Z9? Email
APPLICANT':
Mailing
City: Stals:_Zip: Contact No:
'Please fill oul applicant information it different than landowner
Email:
CONTACT NAME APPLYING IN OFFICE: Phone
PROPERTY LOCATION: Subdivision: — / Vf'i- —//���11 __ �/ Lot #: Lot Size : J O(LVI S
State Road # e- J_ State
?Road Name: CO CAVI Cyuy la vu-- 1014 /
Parcel: V _(-1 SUS ONA 9 q 51 (II Book 8 Page:
�/ /� PIN: �1? � ,r"_� 7" ✓ / 4�.��a
Zoning:�f_ Flood Zone: /� Watershed: V� S Deed Book & Page: SZS7 t -%7 Power Company':
'New structures with Progress Energy as service provider need to supply premise number
PROPOSED USE:
from Progress � Energy. � z
Monolithic
❑ SFD (Size _x_) # Bedrooms:, # Baths:_ Basement(w/wo bath):_ Garage:_ Deck:_ Crawl Space:_ Slab:_ Slab:_
(is the bonus room finished? (_) yes (_j no w/ a closet? (_j yes (_) no (if yes add in with # bedrooms)
7 Mod: (Size _x_) # Bedrooms_ # Baths_ Basement (w/wo bath)_ Garage:_ Site Built Deck:_ On Frame_ Off Frame_
(Is the second floor finished? (__) yes (_) no Any other site built additions? (_j yes (J no
❑ Manufactured Home:
_SW _DW _TW (Size
x_) If Bedrooms: _ Garage:_(ske built?_) Deck:_(site buill?_)
❑ Duplex: (Size _x_)
No. Buildings:
No. Bedrooms Per Unit:
❑ Home Occupation: If Rooms:
Hours of Operation: #Employees:_
" Addition/Accessory/Other: (Size _x_) Use: %. V ��i Q� i"VOTONA L Closets in addition? (_j yes (_)no
Water Supply: --X— County _ Existing Well _ New Well (# of dwellings using well )'Must have operable water before final
Sewage Supply: _ New Septic Tank (Complete Checklist) X Existing Septic Tank (Complete Checklist) _ County Sewer
Does owner of this tract of land, own land that contains a manufactured home within five hundred feet (500') of tract listed above? U yes (_j no
Does the property contain any easements whether underground or overhead (_j yes ()6 no
Structures (existing or proposed): Single family dwellings: J— Manufactured Homes: Other (specify): �-
Required Residential Property Line Setbacks:
Front Minimum Actual
Rear
Closest Side
Sidestreet/comer lot
Nearest Building _
on same lot
Residential Land Use Application
Page 1 of 2
APPLICATION CONTINUES ON BACK
SPECIFIC DIRECTIONS TO THE PROPERTY FROM LILLINGTON:
If permits are granted I agree to conform to all ordinances and laws of the State of North Carolina regulating such work and the specifications of plans submitted.
I hereby state that foregoing statements are accurate and correct to the best of my knowledge. Permit subject to revocation if false information is provided.
Signature of Owner or ner's Agem Da
—It is the ownerlapplicants responsibility to provide the county with any applicable Information about the subject property, Including but not limited
to: boundary information, house location, underground or overhead easements, etc. The county or its employees are not responsible for any
Incorrect or missing Information that Is contained within these applications.*"
"This application expires 6 months from the Initial date if permits have not been Issued"
Revocnt,al Land Use Application Page 2 of 2 03/11
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APPLICATION#: J]–S-bD41 (?>S
;This application to be filled out when applying for a septic system inspi lion.•
IF THE INFORMATION IN THIS APPLICATION IS FALSIFIED, CHANGED, OR THE SITE IS ALTERED, THEN THE IMPROVEMENT
PERMIT OR AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. The permit is valid for either 60 months or without expiration
depending upon documentation submitted. (Complete site plan = 60 months: Complete plat = without expimtioq �
910-893-7525 option I CONFIRMATION�t_{� qhb -02 1
❑ Environmental Health New Septic SvstemCode 800 `� 1
• All orooerty Irons must be made visible. Place "pink property flags" on each corner iron of lot. All property
lines must be clearly flagged approximately every 50 feet between corners.
• Place 'orange house corner flags" at each corner of the proposed structure. Also flag driveways, garages, decks,
out buildings, swimming pools, etc. Place flags per site plan developed al/for Central Permitting.
• Place orange Environmental Health card in location that is easily viewed from road to assist in locating property.
• If property is thickly wooded, Environmental Health requires that you clean out the undergrowth to allow the soil
evaluation to be performed. Inspectors should be able to walk freely around site. Do not grade property.
• An /nee in hn nddrnnmA...r•u.. •n •..._.____ -___ _ _. _
• After preparing proposed site call the voice permitting system at 910-893-7525 option 1 to schedule and use code
800 (after selecting notification permit if multiple permits exist) for Environmental Health inspection. Please note
confirmation number given at end of recording for proof of request
• Use Cltck2Gov or IVR to verify results. Once approved, proceed to Central Permitting for permits.
Environmental Health Existing Tank Inspections Code 800
• Follow above instructions for placing flags and card on property.
• Prepare for inspection by removing soil over outlet end of tank as diagram indicates, and lift lid straight up (if
possible) and then put lid back In place. (Unless inspection is for a septic tank in a mobile home park)
• DO NOT LEAVE UDS OFF OF SEPTIC TANK
• After uncovering outlet end call the voice permitting system at 910-893-7525 option 1 & select notification permit
if multiple permits, then use code 800 for Environmental Health inspection. Please note confirmation number
given at end of recording for Proof of request.
• Use Click2Gov or IVR to hear results. Once approved, proceed to Central Permitting for remaining permits.
SEPTIC
If applying for authorization to construct please indicate desired system typc(s): can be ranked in order of preference, must choose one.
(—I Accepted I_) Innovative I_) Conventional I_) Any
I_) Alternative {_) Other
The applicant shall notify the local health department upon submittal of this application if any of the following apply to the property in
question. If the answer is "yes", applicant MUST ATTACH SUPPORTING DOCUMENTATION:
{_) YES
O NO
Does the site contain any Jurisdictional Wetlands?
(__ I YES
{Y) NO
Do you plan to have an inagatjpn s; std now or in the future?
(—)YES
(Y) NO
Does or will the building contain any drains? Please explain.
(I—)YES
1_1 NO
Are there any existing wells, springs, waterlines or Wastewater Systems on this property?
{ _ I YE S
( Zl ) NO
Is any wastewater going to be generated on the site other than domestic sewage?
(_ IYES
) ') NO
Is the site subject to approval by any other Public Agency?
f _) YES
(,4, ) NO
Are there any Easements or Right of Ways on this property?
IL )YES
I_) NO
Does the site contain any existing water, cable, phone or underground electric lines?
If yes please call No Cuts at 800-6324949 to locate the lines. This is a free service.
1 Have Read This Application And Certify That The Information Provided Herein Is True, Complete And Correct. Authorized County And
State OMcfals Are Granted Right Of Entry To Conduct Necessary Inspections To Determine Compliance With Applicable Laws And Rules.
1 Understand That 1 Am Solely Responsible For The Proper Identification And Labeling Of All Property Lines And Corners And Making
The Site AcWsible So That A Complete S* Evaluation Can Be Performed.
OR OWNERS LEGAL REPRESENTATIVE SIGNATURE (REQUIRED) DATE
Irmo