LAND USE Initial Application Date: ?- 7 /I Application # 1/ 577g 2‘ i 9 f
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COUNTY OF HARNETT RESIDENTIAL LAND USE APPLICATION
Central Permitting 108 E. Front Street, Lillington, NC 27546 Phone: (910) 893 -7525 Fax: (910) 893 -2793 www.harnett.org /permits
Ain LANDOWNER: / ('r ANA ./!J A /cr ■ S - R, $$A/F Mailing Address: 3O6 6 F /&GROG /ND 1.4
Cit 2UNn1 State:/ Zip: Zf337Contact# 9 /9- 220-0 //f/ Email: G($,%bbCCCl) c V7 a StiiUkfr /i ?
APPLICANT *: / ,er , 52A/3Le9 Mailing Address:
City: State: Zip: Contact # - Email:
'Please fill out applicant Information if different than landowner
CONTACT NAME APPLYING IN OFFICE: R , CrA /FR Phone #
/ r /
PROPERTY LOCAT /t Subdivision: : [ � � I . 6 / .' Lot #: Lot Size: 7 6- / 2_
State Road # /7 ! y
0 0 State Road Name: lib , 't9 x"'/ �^ , l Map Book &Page: 20 / � y 7 / 5Or'O
Parcel: 92 1 �w PIN: ir 1,
v- &
• Zoning: P & Flood Zone: / Watershed: / Deed Book &Page: L p/ / ) f 7 Power Company *:
New structures with Progress Energy as service provider need to supply premise number from Progress Energy.
SPECIFIC DIRECTIONS TO THE PROPERTY FROM LILLINGTON: NC 2 EAaST TO / /ant 4 4 X /6/t 4
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PROPOSED USE:
Monolithic
❑ SFD: (Size _x_) # 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)
: (Size .28 x 76 ) # Bedrooms i # Baths2 Basement (w /wo bath)_ Garage:_ Site Built Deck: j On Frame_ Off Frame
Mod e
(Is the second floor finished? (_) yes (Ino 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: Hours of Operation: #Employees:
❑ Addition /Accessory/Other: (Size _x_) Use: Closets in addition? (_) yes (_)no
Water Supply: _ County Existing Well t/ /' New Well (# of dwellings using well / ) 'MUST have operable water before final
Sewage Supply: V 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 no
Structures (existing or proposed): Single family dwellings: 40/I Manufactured Homes: Other (specify):
Required Residential Property Line Setbacks: Comments:
Front Minimum �' Actual z6 z
Rear 24
f25"
Closest Side /0 _La
SidestreeVcomer lot
Nearest Building
on same lot
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 state ents are accurate and correct to the best of my knowledge. Permit subject to revocation if false information is provided.
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Signature of Owner Owner's Agent D3ate
**This application expires 6 months from the initial date if permits have not been issued**
A RECORDED SURVEY MAP, RECORDED DEED (OR OFFER TO PURCHASE) AND PLAT ARE REQUIRED_WHEN APPLYING FOR LAND USE APPLICATION
Residential Land Use Application Page 1 of 1 07/10
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NAME: APPLICATION #: 11 2 4 O / 9
*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
d endi upon documentation submitted. (Complete site plan =60 months; Complete plat = without expiration)
910- 893 -7525 option 1 CONFIRMATION #
u Environmental Health New Septic SvstemCode 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 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 comers 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 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 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
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 type(s): can be ranked in order of preference, must choose one.
{_) Accepted {_} Innovative {LiConventional {_} Any
(_} Altemative {_} 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 {1N0 Does the site contain any Jurisdictional Wetlands?
(_} YES I ✓ } NO Do you plan to have an irrigation system now or in the future?
{_}YES { ✓rNO Does or will the building contain any mss? Please explain.
)YES I�NO Are there any existing wells, springs, waterlines or Wastewater Systems on this property?
}YES IO Is any wastewater going to be generated on the site other than domestic sewage?
OYES YES (_ NO Is the site subject to approval by any other Public Agency? 24.9 _ Won't P
ACM I Of / 012elyke y
(1/1YES { NO Are there any Easements or Right of Ways on this property?
(_ }YES {k f 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 Accessible So That A Complete Site Evaluation CC n Be Performed
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PROPERTY OWNERS OR OWNERS LEGAL REPRESENTATIVE SIGNATURE (REQUIRED) D TE
10 /10
Harnett County Department of Public Health
Well Construction Permit Application
If the 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
i at i s%ta- rn-- ( 9/9) X20 — eve y
Applicant /Owner Phone Number
31::16& / ,,kt6Razrn6 4 Avid, NC 28'337
Street Address, City, State, Zip Code
The Applicant must submit a Slte 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 for 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 feet 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:
I. 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 are landscape changed that affect site drainage.
Contact information: Environmental Health Division - 910 - 893 -7547
PROPERTY INFORMATION
•
Proposed use of well
Single - Family Multifamily❑ Church ❑ Restaurant D Business Irrigation
Street Add es Subdivision/Lot #
Parcel # PIN #
Directions to the Site
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I have thoroughly read and completed this Application and certify that the information provided herein Is true, complete and
correct to the best of my 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.
1 understand that I am solely responsible for the proper identification and labeling of all property lines, underground utility lines, and
making the site accessible so so that a wdl can be properly constructed according to the permit
i2Li�7. � 3/7/201/
Property Owner's ofOwner's Legal Representative Signature Required Date
How to Properly Mark Property for Soil Evaluation
(MUST MATCH SITE PLAN)
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Area NC 111811 }24 N
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Excise Tax: S 124 i
Parcel identifier No 02 : at! ; ' 8 trifled by County on the _ day of , 20
By
MeiWBax 1a Lynn A. Matth A. ' e I Commerce Drive, Suite B, Dunn, NC 28334
This tttsutnnent was prepared by: Lvn M • ,- , 08 Comer= Drive, Suite B, Dunn, NC 28334
Brief description ihr the Index: LO • . d 110, Page 505,
THIS DEED made this gik day of -.. �• ' , 20 by and between
GRANTOR Vir GRANTEE
Montgomery Ballard, Sr. and wife, drew Stabler and wife,
Joyce A. Ballard Janet en Stabler
30 Pilgrim's View Lane Fai . • and Road
Dunn, NC 28334 S �D , N 28334
Enter in appropriate block for each Grantor and Grantee: name, mails _ , if appropriate, character of eanity, e.g.
corporation or partneSiip.
The designation Grantor and Grantee as used herein shall include sa• • • - censors, and assigns, and shall include
singular, plural, masculine, feminine or neater as required by context.
WITNESSETH, that the Grantor, for a valuable consideration paid by the it ichIs hereby acknowledged, has and
by these presents does grant, bargain, sell and convey unto the Grantee in fee a n that* of or parcel of land situated in the
City of Dunn Averesboro Township, County, North Carolina
and more particularly described as follows:
See Exhibit A attached hereto and made a part hereof.
The property hcreitmbove described was acquired by Grantor by instrument recorded in Hook 13 : e Ail or a portion of the property herein conveyed _ includes or doea not include the primary reai. A map showing the above described property is recorded in Plat Hook 2010 page 805
NC Bet Nwelalon Form No. 3 A IOC Revised 0 1/113010
hind by Augment with the NC Boo Ass a laticu
Ileir