DOCUMENTS Initial Application Date:Ly f 6/ I 11 Application# I fi S�.J�/ ` i g
COUNTY OF HARNETT LAND USE APPLICATION
Central Permitting 108 E.Front Street,Lillington,/ NC 27546 Phone:(910)893-7525 Fax:(910)893-279933 www.harnett.org
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LANDOWNER: Nark a Lori [ y�, Mailing Address:
q 18662 p 14,1547hi3 Pri
City: ANN State: � Zip: Ii3.T�4- Home#: '111!'!!2Q/ ^ 1z'1p4-1 Contact F:
APPLICryANT•:�IIl /.Y/lkh*`J L•. .,^ Mailing Address: 61775.7 fµ. Z7 easi/� Q• �p�..
City: Calf 1 State: PIP, Zip: ZT� Home#: 91'1 Bit J Contact it: ?Ai :/Z#-ASL
*Please fill out appl ant Information if different than landownernd' ( JJ
PROPEReTYY LOCATION:
I _Staatte�Road t:1S�Z State Road Name: LGAts4t& I , /or AC
Parcel: �/v�,�11`USQ p- 11-n c1 u, PIN:\ �n v�. - b, ' /�L •G�� ^ (�
Zoning:ANTA c Subdivision: K11_71 l �1.r .01 C)rY Th � LotLo #:. ^ LI
0 Lot Size: �OT,Z�•, l�1SIOJ' I
Flood Plain: (� Panel: Watershed: /�-4 f,/ Deed Book/Page: � L ^/ 3LI Plat Book/Page:� agal IIT T`I
SPECIFIC DIRECTIONS TO THE PROPERTY FROM LILLINGTON: 42! jD 27 tali ID Skyio TCWQ O,mts
hiyl u�?J 55 /eft on Leann& 3 Ail lei pm kg- d
PROPOSED USE: Circle:
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Circle:
1L SFD(Size /JV x Ca!)#Bedrooms #Baths!?IPI Basement(w/wo bath)_ Garage ✓ Deck sArtnris
❑ Modular'._On frame Off frame(Size_x_)#Bedrooms #Baths Garage (site built? )Deck (site built? )
❑ Multi-Family Dwelling No.Units No.Bedrooms/Unit
❑ Manufactured Home: SW_DW TW(Size x ) #Bedrooms Garage_(site built? )Deck (site built?_)
❑ Business Sq.Ft.Retail Space Type _ #Employees: Hours of Operation:
❑ Industry Sq.Ft. Type _ _#Employees: Hours of Operation:
❑ Church Seating Capacity #Bathrooms Kitchen
❑ Home Occupation (Size_x ) #Rooms Use Hours of Operation:
❑ Accessory/Other (Size_x_) Use
❑ Addition to Existing Building (Size_x ) Use Closets In additionUyes (_)no
Water Supply: (.V1 C9unty (_) Well (No.dwellings_) (_) Other
Sewage Supply: (j New Septic Tank(Must fill out New Tank Checklist) (_)Existing Septic Tank ( )County Sewer (_)Other
Property owner of this tract of land own land that contains a manufactu d ho wan five hundred feet(500)of tract listed above? LYES (_)NO
Stmctures on this tract of land: Single family dwellings u ac ured Homes Other(specify)
Required Residential Property Line Setbacks: Comments:
Front Minimum 15 Actuall2an Cis
Rear 25
Side LAY
Sldestreet/comer lot 20
Nearest Building 10
on same lot
If permits are granted I agree to conform to all ordinances and the laws of the State of North Carolina regulating such work and the specifications of plans
submitted. I hereby state that the foregoing statements are accurate and correct to the best of my knowledge. This permit is subject to revocation if false
Information is provided on this form.
gat t 20,0
Signature of r or Owners Agent
"This application expires 6 months from the Initial date If no permits have been Issued••
A RECORDED SURVEY MAP,RECORDED DEED(OR OFFER TO PURCHASE)AND PLAT ARE REQUIRED WHEN APPLYING FOR LAND USE APPLICATION
Please use Blue or Black Ink ONLY
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NAME: &r Jill( APPLICATION#:
*This application to be 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
depending upon documentation submitted. (Complete site plan=60 months:Complete plat=without expiration)
910-893-7525 option 1 CONFIRMATION#
Environmental Health New Septic SvstemCode 800
• All oronertv 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/tor 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.
• 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 (after selecting notification permit if multiple permits exist) for Environmental Health inspection. Please note
confirmation number given at end of recordina for proof of request.
• Use Click2Gov 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 LIDS 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
qiven at end of recordina 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 t)pe(s 1: can be ranked in order of preference.must choose one.
II Accepted {___I Innovative 1ylirConventional {_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:
1_IYES { liitI NO Does the site contain any Jurisdictional Wetlands?
!_IYES 1Jel NO Do you plan to have an irrigation system now or in the future?
{ 4YES { } NO Does or will the building contain any drains?Please explain. Howse _.
I )YES t f NO Are there any existing wells,springs, waterlines or Wastewater Systems on this property?
I—IYES {✓�NO Is any wastewater going to be generated on the site other than domestic sewage?
{ IYES { F) NO Is the site subject to approval by any other Public Agency?
!_IYES { gINO 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
Stale 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 For The Proper Identification And Labeling Of All Property Lines And Corners And Making
The Si essible So That�y9omylele Site Evaluation Can Be Performed.
lfiL'G/f//JL79d 1-.9 /7
PRO RTY O ERS OR OWNERS LEGAL REPRESENTATIVE SIGNATURE(REQUIRED) DATE
ID/10
I hereby certify that I nave the autnonty to make necessary application that the application is correct
and that-the construction will conform to the regulations in the Building Electrical Plumbing and
Mechanical codes and the Harnett County Zoning Ordinance I state the information on the above
contractors is correct as known to me and that)v manilla below I have obtained alt subcontractors
permission to obtain these permits and if gay changes occur including listed contractors site plan
number of bedrooms budding and trade plans Environmental Health permit changes or proposed use
changes I certify it is my responsibility to notify the Harnett County Central Permitting Department of
any and all changes
EXPIRED PERMIT FEES-8 Months to 2 years permit re-issue fee is$150 00 After 2 years re-issue fee
is4'%i4
current fee schedule
h l and 2/1 ZD/7
Sr/Contractor/Officer($)of Corporation e
Affidavit for Worker's Compensation N C G S 87.14
The undersigned applicant being the
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V General Contractor _Owner Officer/Agent of the Contractor or Owner
Do hereby confirm under penalties of perjury that the person(s) firm(s)or corporation(s)performing the work
set forth in the permit
Has three(3)or mote employees and has obtained workers compensation insurance to cover them
Has one(1)or more subcontractors(s)and has obtained workers compensation insurance to cover
them
Has one(1)or more subcontractors(s)who has their own policy of workers compensation insurance
covering themselves
_Has no more than two(2)employees and no subcontractors
While working on the project for which this permit is sought't Is understood that the Central Permitting
Department issuing the permit may require certificates of coverage of workers compensation insurance pnor
to issuance of the permit and at any time during the permitted work from any person firm or corporation
carrying out the work .
Company or Na elders LLC ���///
sign*The AI.Iy (([ &WNf t Date e6i7