DOCUMENTS Initial Application Date:lc)1 �1 - / Application '15L_Jl-i-4 I " 31-1
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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.barneh orglpermits
"A RECORDED�SURVEY MAP,RECORDEDE/� DEED(OR OFFER TO PURCHASE)8 SITE PLAN ARE REQUIRREgD WHEN SUBMITTINNGy-A LAND USE APPLICATION"
LANDOWNER:C ( {IOWd3 �T. 6r�/�Y/s�<s elk Mailing Address: (i /G32 PCl�rclf T'Cr,,
City: SRM Fns" State:-)_ry,Zipiyr3�Contact No: 1I6 k31 Y}-9 KZ Email:
s
APPLICANT': SJntt Mailing Address:
City: State: Zip: Contact No: Email.
'Please fill out applicant information if different than landowner
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CONTACT NAME APPLYING IN OFFICE: COW s/ x-+IDBS Phone# 9/a ' 43q-1rq ii r�G
PROPERTY LOCATION:r� TSubdivision: ,app/ IIA, Lot#. LotoSize: I•7 4
State Road# 12.1 I State Road Name:( t! IVI; I I 0/,� �'S'^ Map Book&Pa(geeO^0O // SS
Parcel. Ot 'RSA �(/ fOJl.9�7 PIN: q..
0"7
-c>a - 34S • O w/
Zoning SA lood Zone: X Watershed:A Deed Book 8 Pager W I/ I 37 Power Company'-.
'New structures with Progress Energy as service provider need to supply premise number from Progress Energy.
PROPOSED USE:
Monolithic
.rD:(Sizex_ ')#Bedrooms ._#Baths: Basement(w/wo bath): Garage. Deck:_Crawl Space_Slab: Slab.
(Is the bonus room finished?(_)yes ( )no cal a closet?( )yes ( )n__o(if yeslI�add in with#bedroom , j,�y
p q I p Sr CA J`.otai ` `FpleV\ Vl
Mod:iii (Size 3a x C 4)#Bedrooms,L#Baths Basement(w/wo bath)_Garage':_Site Built Deck: ‘_4td°rame Off Frame./
(Is the second floor finished?( )yes ( )no Any other site built additions?(_)yes ( )no
❑ Manufactured Home:_SW OW TW(Size x )fl Bedrooms:_Garage: (site built? )Deck: (site built? )
❑ Duplex.(Size x )No.Buildings: No.Bedrooms Per Unit:
❑ Home Occupation:#Rooms: Use: Hours of Operation. #Employees:_
❑ Addition/Accessory/Other(Size x )Use: Closets in addition?(_)yes ( )no
Water Supply: County Existing Well New Well(#of dwellings using well )'Must have operable water before final
Sewage Supply: New Septic Tank(Complete Checklist) 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?(_)yes �1 no
Does the property contain any easements whether underground or overhead(4 yes (_J no
Structures(existing or proposed):Single family dwellings: ' Manufactured Homes: Other
(specify):
Required Residential Property Line Setbacks: Comments: 1----;s 1 reuar +.n 13 D (TVY}
Front Minimum JJ Actual I�l6L.SN �1,/ ?lbw , �� �
Rear 2-5 -lu •e- S `Cmc t . iort
Closest Side 10 1-114,L t [YL✓-..
Sidestreeticorner lot
Nearest Building
on same lot
Residential l and Use Application Page 1 of2 03/11
APPLICATION CONTINUES ON BACK
4 it
SPECIFIC DIRECTIONS TO THE PROPERTY FROM LILLINGT II 4 . a Y a • A
NtfiK4 au aX u4;rl (2 1.)s kr(re- y iN
If permits are granted 1 agree to conform to all ordinances and laws of the State of North Carolina regulating such work and the specifications of plans submitted.
1 hereby state That foregoing statement accur and correct to the best of my knowledge. Permit subject to revocation if false information is provided.
Siignaturof Owner or Owner's AgentPr ate
"'h is the owner/applicants 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"
Residential Land Use Application Page 2 of 2 03111
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NAME: Q/ 1yf�/ �YbsS APPLICATION#:
/ *This application to he filled out when applying for a septic system Inspection.*
County Health Department Application for Improvement Permit and/or Authorization to Construct
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
dependin upon documentation submitted. (Complete site plan=60 months;Complete plat=without expiration)
910-893-7525 option I CONFIRMATION#
Environmental Health New Septic System Code 800
• All property 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 at/for Central Permitting.
• Place orange Environmental Health card in location that is easily viewed from road to assist in locating properly.
• 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.
• All lots to be addressed within 10 business days after confirmation. $25.00 return trip fee may be incurred
for failure to uncover outlet lid,mark house corners and property lines,etc. once lot confirmed ready.
• After preparing proposed site call the voice permitting system at 910-893-7525 option 1 to schedule and use code
800 (atter 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 Click2Gov or IVR to verify results. Once approved, proceed to Central Permitting for permits.
') Environmental Health Existina 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 LIDS OFF OF SEPTIC TANK
• Atter 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 desire ystem typels): can be ranked in order of preference.must choose one.
IJ Accepted { I Innovative { Conventional II Any
I_l Alternative 1I 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:
I—IYES {;/NO Does the site contain any Jurisdictional Wetlands!
I_IYES (iI NO Do you plan to have an irrigation system now or in the future?
1-1 YES {bit NO Does or will the building contain ally drains?Please explain.
IJ YES l vl NO Are there any existing wells. springs. waterlines or Wastewater Systems on this property?
IIYES IA/NO Is any wastewater going to he generated on the site other than domestic sewage?
IIYES I_C(NO Is the site subject to approval by any other Public Agency?
I(IYES I_I NO Are there any Easements or Right of Ways on this property?
I/YES { I NO Does the site contain any existing water,cable,phone or underground electric lines?
If yes please call No Cuts at 800-632-4949 to locate the lines. This is a free service.
I Have Read This Application And Certify That The Information Provided Herein Is True,Complete And Correct. Authorized County And
State Officials Are Granted Right Of Entry To Conduct Necessary Inspections To Determine Compliance With Applicable Laws And Rules.
I Understand That I Am Solely Responsible Fur The Proper Identification And Labeling Of All Property Lines And Corners And Making
The Site Accessible S hat A Complete Site Evaluation Can Be Performed.
OHf /6
PROPERTY OWNERS bR OWNERS LEGAL REPRESENTATIVE SIGNATURE(REQUIRED) - A
l/ 10/10
Harnett County Department of Public Health
Well Construction Permit Application
lithe information in the application for a Well Construction Permit is falsified,
changed,or the.site is altered, then the Well Construction Permit shall become
invalid.
APPLICANT INFORMATION
�o i q10 ) 639- A'F9rra2
Applicant' caner P �l(`r���}l- �p`1 P�hh^on.Number
Street Address,Cit/y3lfartte,Zip Code 1 c S!µ/ v " N/ a 73i,
The Applicant must submit a Site Plan. The Site Plan is a map/drawing of the property and must show:
I.existing and/or proposed property lines and easements with dimensions:
2.the location of the facility and appurtenance;
3.the location far the proposed well;
4.the location of existing or proposed sewer lines and/or sewage disposal systems within 100 feet or the proposed well:
5.the location of any existing wells within 100 feet of the property;surface water bodies;
6.above ground and/or underground storage tanks;
7.and any other known sources of contamination within 100 feel of the proposed well site.
The Applicant shall notify the Harnett County Health Director through or by way of the Harnett County
Division of Environmental Health If any of the following occur prior to well construction:
1.there is a relocation of the proposed facility;
2.there is a change in the intended use of the facility;
3.there is a need for installing the waste water system in an area other than indicated on the well permit;or
4.there arc landscape changed that affect site drainage.
Contact information: Environmental Health Division-910-893-7547
PROPERTY INFORMATION
/ Proposed use of well
Single-Falnil}$! Multifamily) Church Restaurant _: Business __ Irrigation
Street Address Subdivisyy'gqn/Lot#
Parcel# CI 9 S?9 /Osco PIN # 1 t.D1O-�ol1asr(des
Directions to the Site
Ant" t
• altai _
1 have thoroughly read and completed this Application and certify that the information provided herein Is true,complete and
correct to the best of in,knowledge and is give In good faith. Representatives of the Harnett County Health Department and
state officials are granted right of entry to conduct necessary inspections to determine compliance with applicable rules.
I understand that/am sole&responsible lar the proper identilicarion and labeling 01 all lines.underground:who lines.and
making the cue aroesstble so that a ma ran be propen,constructed aceordtng m the peanut
g 4/4,//7
Property Owner's of Ow Legal Representative Signature Required D