DOCUMENTS Initial Application Dates 13a) ,$ Application# 1 e 5C:CM 31� a
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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.hametl.orglpennits
"A RECORDED`_ SURVEY MAP,RECORDED DEEDDE (OR OFFER TO PURCHASE)&SITE PLAN ARE REQUIREDREWHEN SUBMITTING A LAND USE APPUCATION"
LANDOWWN.ER�/:Lk:NA'A ✓E"-'w/j^,s` Mailing Address: 370 OCEo/T-6/4. e v5 /w,I,
City: AA6, t.. `/`, State:/A" Zip�4`5V Contact No: W90//Tf�//51- /Eymail::JJ TR/4/6 o&Nt Cs/n
APPLICAJJNT':t)0 M'A w/x�L'� ZC Mailing Address: .a b Gass Q y%" Deigi�1 /�T
City: Nola. state::Zipr/f0 i Contact No: 9/2c4'po//f Email:✓]€SS/69coszo1L,cot
'Please fill out applicant information if different than landowner 11nn1� S‘..-1Z.
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CONTACT NAME APPLYING IN OFFICE: �I� �YIl Nv1 S'\\ Phone# l '� 1 IJ - isi
PROPERTY LOCATION:Subdivision: Gross L NJ-c. Lot#: 4 Lot
LotSizet:
-CT
State Road# 3 U State Road Name: lJ v S 5 ( (No, Map Book&Pagel7C+ze!I‘tCA
Parcel: (Hatt k �j—t 4- bt't PIN: VL `t q .— (Q1 t I 3t ra'V
Zoningq40/b4).1/4 Flood Zone: WatershedlU
Deed Book&Page345 ) /355 Power Company:
*New structures with Progress Energy as service provider need to supply premise number from Progress Energy.
PROPOSED USE:
Monolithic
❑ SFD:(Size x )1/Bedrooms:_#Baths: Basement(wlwo bath):_Garage_Deck: Crawl Space:_Slab:_Slab:
(Is the bonus room finished?(_)yes (_)no w/a closet?( )yes ( )no(if yes add in with#bedrooms)
❑ 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?(_)yes (_)no
❑ Manufactured Home:_SW_DW TW(Size x )#Bedrooms:_Garage: (site built?_)Deck:_(site built )
❑ Duplex:(Size x_)No.Buildings: No.Bedrooms Per Unit:
❑ /Home Occupation:#Rooms: Use: CYC T� Hours of Operation: &Employees: L
Cl/
Addition/Accessory/Other:(Size /7 x�)Use: //v ED Closets in addition?(_)yes (rl)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 yy
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� ( )yes (x)no F,
Structures(existing or proposed):Single family dwellings: 1 &XT Manufactured Homes: Other(specify): \ =cell.
Required Residential Property Line Setbacks: Comments: �J1s':1. '�.1'
Front Minimum nOS Actual (
Rear n aST
Closest Side `V NiS
SidestreeVcomer lot
Nearest Building A,yp 5
on same lot
Residential Land Use Application Page 1 of 2 03/11
APPLICATION CONTINUES ON BACK
•
SPECIFIC DIRECTIONS TO THE PROPERTY FROM LILLINGTON: 7:41. 9)f /044110.5 /caAq / 4.c6
A Rt Nr UN Cl/AckeM rgSRR4961 ,e0 > rk R/brrl osv ORDs3'04/4'ago"
,4'a€ (13-'by R/6vy
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 foregoi statements ur nd correct to the best of my knowledge. Permit subject to revocation if false informafion is provided.
jah(VA Sti/W5* "Sidi 12?
Signature of Owner or Owner's Agent Date
mit 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 forbny
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 0301
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NTL#AP's=35-7319 Harnett County Department of Public Health
24241
PERMIT# ZSSSOperation PerL/pit
IV New Installation IU!'Septic Tank CYNitrifi atro Line ❑ Repair ❑ Expansion
PROPERTY LOCATION:Tot/Y 9 ��`r"+-g .�
Name: (owner) [ .riot L� `�"'r' SUBDIVISION �e,e.n.,.a,(�:fe `bT # a(
System Installer: 7t, 'A f Bed _ _ Registration #
Basement with plumbing: C Garage L. be of Bedrooms 3 _
Type of Water Supply: J Community 1 le Public LT Well Distance from well leer
System Type: 7S%ii as.at'.Od` iCf/ iy,ee4 aske,(4_,.fid VI Systems expire in 5 years.
(In accordance with Table Y a( / / Owner must contact Health Department 6 months
p prior to expiration for permit renewal.
a Ra
!hit quem has been tamed in compliance with applicable Norah(SIN General Statute'.Rules for Seta: • r i iipoul, d ill condition;of IN Improvement Permit and Cowman awamrumon.
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PERMIT CONDITIONS
I. Performance: System shall perform in accordance with Rule .1961.
II. Monitoring: As requited by Rule .1961.
III. Maintenance: As required by Rule .1961. Other
Subsudue system operator required? Yes ❑ No
If yes, tae attached sheet for additional operation conditions. maintenance and reporting.
N. Operation:
V. Other:
❑ D-Box ❑ Pump ❑ Alarm ❑ [Maine ❑ PWR Line
following are the specifications for the sewsposal system on the above captioned property.
Type of system: 01 Conventional 7,1 Other 75Z/Lt.& Septic lank: /060 gallons Pump Tank: / ora ° ga%ons
Subsurface No, of exact length 1 width of p depth of
I
Drainage field ditches 3 of each ditch pfeet ditches fen ditches 7C9 7IIndies
french Drain Required: Linear feet
Authorized State Ag de____ /'F. A f' Date 1[)—Ic'tV
NTE# /6- S- 36799 Permit # 2 '6'211
IIarnett (bunty I)epartmeutof Public Health
Site Sketch
PROPERTY LOCATON:bat_1-I 4 t karst t j�, XU)
ISSUED TO: Pwr_.. F(.n--, irc ___ SUBDIVISION -4-n-a- --.-Gu LOT #
Authorized State Agent: ---, ./.2i Date: 7- 7- (i
Cad-aa'-vu, i'h3227 - (M) s- e. � � dk .x)57-4 1,
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NAME: APPLICATION#:
*This application to be tilled 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 SystemCode 800
• All property irons must be made visible. Place 'pink properly 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 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 it 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 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 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 type(s): can be ranked in order of preference,must choose one.
I Accepted { ) Innovative i_) Conventional { I Any
{_j Alternative {_I 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 { I NO Does the site contain any Jurisdictional Wetlands?
{_}YES { I NO Do you plan to have an irrigation system now or in the future?
{ }YES 1_1 NO Does or will the building contain any drains?Please explain.
IIYES i )NO Are there any existing wells,springs,waterlines or Wastewater Systems on this property?
{_}YES {_I NO Is any wastewater going to be generated on the site other than domestic sewage?
{_}YES {_I NO Is the site subject to approval by any other Public Agency?
{_}YES { I NO Are there any Easements or Right of Ways on this property?
{_)YES {_1 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 For The Proper Identification And Labeling Of All Property Lines And Corners And Making
The Site A ass' le So That mp t Site Evaluation Can Be Performed.
03 e oa 5 �e 3 /I
PROPE Y OWNERS OR OWNERS LEGAL REPRESENTATIVE SIGNATURE(REQUIRED) AT
10/10
08/08/11 Application#
Harnett County Central Permitting
PO Box 05932793 NC 27546
Each section below to be Med outhornetrne
8109937625 Fax 910997 2793 www n orgrpermda
by whomever por work
Must be owner or honed
w^b.ctor Address company Application for Residential Bsildma and Trades Permit
name a phone must match
Owners Name J( 4 51&4 Z& Date 3/alll8
Site Address Zit CPIs CI44‘ L/u6A•ubjg2 ftC Zan/ Phone 9/9 679-0/5"
Directions to job site from Ludington 14MB c10j istmA5 MikG4YA4nhd RJ6 Tan!
Ck cobti smoti6S Ro /Mau R/641c9U cRoas QA,g Day, /s
°Ai 1>y6,C16N9
Subdivision Cleo SS. 0(1k Lot V
Description of Proposed Work /? ao SN60 #of Bedrooms
Heated SF Unheated SF Finished Bonus Room?_Crawl Space _Slab ✓
• • I .F.^. •. u • u x..11
alrjor 8441 ®uwfJZ 305W94 /6MILLSffie Ma' 9i36q$o/lF
Building ConfracWr s Company Name Telephone
370 ciens 644i DA Avb/612iii<e)43/ Jft6d/69OJ6a4K,VVrlf
Address Email Address
Lscdnse#
glectrrcal Contractor Information
Descnpton of Work Service Size _Amps T-Pole _Yes_No
Electrical Contractor s Company Name Telephone
Address Email Address
License#
Mechanical/HVAC Contractor Information
Description of Work
Mechanical Contractors Company Name Telephone
Address Email Address
License#
plumbrna Contractor Information
Description of Work #Baths
Plumbing Contractors Company Name Telephone
Address Email Address
License#
Insulation Contractor Information
Insulation Contractors Company Name 8 Address Telephone
*NOTE General Contractor must fill out and sign the second page of this application
I hereby certify that I have the authonty to make necessary application that the application is correct
and that-the construction will conform to the regulations in the Budding Electncal 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 yv waning below I have obtained all subcontractors
permission to obtain these aermrts and if any 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-6 Months to 2 years permit re-issue fee is 6150 00 After 2 years re-issue fee
is as per current fe schedule
3/427
Sig lure of Owner/Contractor/Officer(s)of Corporation Date
Affidavit for Worker's Compensation N C G 3 87-14
The undersigned applicant being the
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 more 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 witch this permit is sought it 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 dunng the permitted work from any person firm or corporation
carrying out the work
Company or Name Ap �j�
Sign wattle �Ye'Wt>J� — Date gJ /J/7
HARNETT COUNTY CASH RECEIPTS
*** CUSTOMER RECEIPT ***
Oper:Date: J3/OCK/22/18 52 ReceiptpDrawer:
no: 296728
Year Number Amount
2B18 50843622
380 CROSS LINK DR
ANGIER, NC 27581
B4 BP - ENV HEALTH FEES
fIB8.8B
EXT TANK
SEHULSTER JOSHUA D
Tender detail f10B.BB
CP CREDIT CARD 1100.00
Total tendered 1100.80
Total payment
Trans date: 3/22/18 Tine: 13:34:43
** THANK YOU FOR YOUR PAYMENT **