20060399 Ver 1_Minor Variance_20060310

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OFFICE USE ONLY: Date Received
State of North Carolina
Department of Environment and Natural Resources
Division of Weber Quality
Request #
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Variance Request Form -for Minor V~~'~~ces ~~ ~~ ~~-
Protection and Maintenance of Riparian Areas Rules
NOTE This form maybe photocopied for use as an original
Please identify which Riparian Area (Buffer) Protection Rule applies.
^ Neuse River Basin: Nutrient Sensitive Waters Management Strategy
Protection and Maintenance of Riparian Areas Rule (15A NCAC 02B
.0233)
^ Tar-Pamlico River Basin: Nutrient Sensitive Waters Management
Strategy Protection and Maintenance of Riparian Areas Rule (15A
NCAC 02B .0259)
^ Catawba River Basin: Protection and Maintenance of Existing Riparian
Buffers (15A NCAC 02B .0243)
Part 1: General Information
(P/ease include attachments if the room provided is insufficient.)
1. Applicant's name (the corporation, individual, etc. who owns the property):
~, Q
2. Print Owner/Signing Offiaal (person legaly responsible for the property and its compliance)
Name: _ GQ; 't~ o A l' ~r~.-.,n ;e of ~"P
Title: ~ wN~2
Street address: o r D -
City, State, Zip: C" ~, ,t v,,v~ !, `~ STS' ~ 2 Q '21 n
Telephone: ~~) ~ h, ~ Q 9 .~ g
Fax: ~ ~
3. Contact person who can answer questions about the proposed project:
Name: ,
Telephone: (gam) .7 ~ ~_ p ~ ,~ 9
Fax: ~_
Email: ~ c ~ a: ~r,~ i o ~S'C . r r. r Gih
4. Project Name (Subdivision, facility, or establishment name -consistent with project name on
plans, speafications, letters, operation and maintenance agreements, etc.):
Version 2: November 2002

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5. Project Location:
Street address:
City, State, Zip:
County:
Latitude/longitude:
6. Directions to site from nearest major intersection (Also, attach an 8'/ x 11 copy of the USGS
topographic map indicating the location of the site):
7. Stream to be impacted by the proposed activity:
Stream name (for unnamed streams label as °UT" to the nearest named stream):
~-~tJo N-e
Stream classification [as identified within the Schedule of Classifications 15A NCAC 2B
.0315 (Neuse) or .0316 (far-Pamlico)]: _ -t"~ /,~,T~ -t-~~ ,~ ~°N~ ~ ,~~~ its,
8. Which of the following permits/approvals will be required or have been received already for
this project?
Required: Received: Date received: Permit Type:
CAMA Major
CAMA Minor
401 Certification/404 Permit
On-site Wastewater Permit
NPDES Permit Including stormwater)
Non-discharge Permit
Water Supply Watershed Variance
Others (specify)
Part 2: Proposed Activity
(Please include attachments if the room provided is insufficient.)
2. State reasons why this plan for the proposed activity cannot be practically accomplished,
reduced or reconfigured to better minimize or eliminate disturbances r~ +ho ~..~~~., ti„~e.,..
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Variance Request Form, page 2
Version 2: November 2000
Description of proposed activity [Also, please attach a map of sufficient detail (such as a plat
map or site plan) to-accurately delineate the boundaries of the land to be utilized in carrying
out the activity, the location and dimension of any disturbance in the riparian buffers
assoaated with the activity, and the extent of riparian buffers on the land. Include the area
of buffer impact in ftz.j:

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3.
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4. Please provide an explanation of the following:
(1) The practical difficulties or hardships that would result from the strict application of this
Rule.

(2) How these difficulties or harciships result from conditions that are unique to the property
involved.
#~~o---~1zT~~~~~ S ~-a 1 u~ l- ,.mod ~. Nr~.~..r~ r'.~ .
(3) If economic hardship is the major consideration, then include a specific explanation of the
economic hardships and the pproportion of the hardship to the entire value of the project.
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Part 3: Deed Restrictions
By your signature in Part 5 of this application, you certify that all structural stormwater best
management practices required by this variance shall be located in recorded stormwater
easements, that the easements will run with the land, that the easements cannot be changed or
deleted without concurrence from the State, and that the easements will be recorded prior to the
sale of any lot.
Part 4: Agent Authorization
If you wish to designate submittal authority to another individual or firm so that they may provide
information on your behalf, please complete this section:
Designated agent (individual or firm):
Mailing address: AGE
City, State, Zip:
Telephone: Q'®~~
Fax:
Email:
Part 5: Applicant's Certification
Variance Request Form, page 3
Version 2: November 2000
Description of any best management practices to be used to control impacts assoaated with
the proposed activity (.e., control of runoff from impervious surtaces to provide diffuse flow,
re-alantin9 vegetation or enhancement of existing ves~etation, etc.):

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(print or type name of person
listed in Part I, Item 2), certify that the information included on this permit application form is
correct, that the project will be constructed in conformance with the approved plans and that the
deed restrictions in accordance with Part 5 of this form will be recorded with all required permit
conditions.
Signature:
Date:
Title:
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Variance Request Forrn, page 4
Version 2: November 2000

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Chis Survey is of an Existing Parcel
utd does not create a new street or
hange an existing one.
Chis Survey is subject to any facts
hat may be disclosed by a frill and
ccarate title search.
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IP =Set Iron Pipe
'P =Power Pole
Mark R. ~ ee
Professional Lan urveyor
P.O. Box 303
Arappahoe NC 28510
TeIe.I# (252 249 - 0226
[e-mail]
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75 Pecan Lane
Kennel's Beach
Township # 1, Pamlico County, North Carolina

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Notes:
For Reference See:
DB 146, PG. 109
Che Ratio of Precision Was
calculated at 1:10,000+
['his Survey is of an Existing Parcel
nd does not create a new street or
hange an existing one.
'his Survey is subject to any facts
hat may be disclosed by a full and
ccurate title search.
~gend:
lP = Existing Iron Pipe
a' =Set Iron Pipe
P =Power Pole
Mask R. Lee
Professional Lan urveyor
P.O. Boa 303
Ara shoe NC 28510
Tele.~ (252 249 - 0226
surveyo~amlico.nd
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Scale: 1" = 20'
A Survev for
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75 Pecan Lane
Kennel's Beach
Township # 1, Pamlico County, North Carolina

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FILED in PAhLICO County, NC
en Jul ZO Z001 et X16 PM
by: Sly FI. WiITFORD
REGISTER OF DEEDS
600K q27 PAGE 193
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This product does not constitute the rendering of legal advice or services. This product is intended for mformat~onal u only and is not a substitute for legal
advice. State laws vary, so consult an attorney on all legal matters. This product was not necessarily prepared by a person licensed to practice law in your state.
LF298-04
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QUITCLAIM DEED
THIS QUITCLAIM DEED, executed this /S day of ~~"~' L ~ , 20 ~ ~,
by first party, Grantor, M ~~~ ~ ~ C~ w~ io ~ C/ec~, Le.r~ J,, ~~C ,
' ~>r<!es ~' ~. 2-766 ~93~
whose post office address is 3 ®®g 1'~1 ~ ~ P ~
to second party, Grantee, ~ q 11`~"lt,e~, ~ C~,o~ m p i a /0 ~R
who~~_IUHNtU IUd/` s 6D'~' OL/~ t~~~a2s 1~~ _
MA_TEUF{RETURNEa ~-~3-moo L-t-~-~ l~ ~~ ~e~ z~ 2 ~ a
WITNESSETH, That the said first party, for good consideration and for the sum of
Dollars ($ )
paid by the said second party, the receipt whereof is hereby acknowledged, does hereby remise, release
and quitclaim unto the said second party forever, all the right, title, interest and claim which the said first
party has in and to the following described parcel of land, and improvements and appurtenances thereto in
the County of ~2 ~ f~'~ ,State of /vo Rrj'~ ~~.tLdL-~r~~ to wit:
~ ~' ! 8 tie cc_ tf 8' ~ 7 ~~ - != !~',

BBC q27 PAGE 194
IN WITNESS WHEREOF, The said first party has signed and sealed these presents the day and year
first above written. Signed, sealed and delivered in presence of:
c
Signet a of Witness Sig atur f First Party
Ja,nef ~1 ~ ~a~ f~ ~~y ~ `
Print n f Wi ess Print name of First Party
Signatur of Witnes Signature o rst Party
Print name of Witness Print nam of First Partv
State of`~or`~~oi;..o.. ~"
County of ~ c~-~i } ~.~ ~~
On ~~ ~ - ~ ~1` ~~ `I before me, ~
- ~
appeared ~~~ ~ - C~"~`n"-d'`o'n a ~, ~ ,
personally known to me (or proved to me on the basis of satisfacto e e to.]ie t per n(s) whose
name(s) is/are subscribed to the within instrument and acknowledg ~$~ the xecuted the
same in his/her/their authorized capacity(ies), and that by his/her/th strument the
person(s), or the entity upon behalf of which the person(s) acted, exec hi .
W TNESS my hand and fficial seal. `~.......~
A
Signature of Notary ~/
AfV~~ _ Known Produced ID
a~e~~~~~~ t~~~a ~ s 9a o
(Seal)
oid oto°o ~9`~a5 gt otOe
State of Qlo~ Ccz~-o1: n~ ~ ,~~~a~~~°r Peg
County of
On t~,r ~ ~ I S~ ~oo~-F before me, ,
appeared ~~ ~(~ (} fln~ M ~ , o ~
personally known to me or prove to me on the basis of satisfactory evidence) to be the person(s) whose
name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the
same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the
person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
WI NESS my hand and fficial seal.
n
............................. .
,1...
Signature of Notary
PAMLICO COUNTY NORTH C,A~'ROLINA
Tho Foregoing Certificate(s) of11~
IsJare certified io correct. "this instrument and this
c~rt~icate are duty registered at the date and time and in
the Book and Page showrn on the first p e Hh~~'o~f~~
Register of Deeds
istant
.~ ,d~~-~
Page 2
Affiant Known Produced .Ip--
Type of ID V~-~-~7~ ~ ~ ~~
(~ (Seal)
\. l_
Signature of Preparer
Print Name of Preparer
Address of Preparer

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Pamlico County Health Department
Division of Environmental Health
PO Boy 306
Bayboro, NC 28515
252-745-5634 Faz:252-745-7684
~t~~a~- J<~1~Ft Wr,~'~1!'Y
AUTHORIZATIONFOR WASTEWATER SYSTEMCONSTRU~~1'~l~°`"~'n ' "'~~'x r~ ~ ~;+aa~ac~~,
YOID SIXTY (60)1t~ONTHS FROMDATE OFLSSUAIITCE
Or Expiration Date of ImurovementPermit
Improvement Perini
Address: (911 Addr~
Mailing Address:
Subdivision Name:
~.,ot #:
AI3THORIZATION CONDITIONS
1. Wastewater system constructions and installation must meet all conditions and specifications as set forth in
Improvement No. ,and the attached site plan with system details. Construction and installation
must also meet all requirements set forth in the rules governing sanitary sewage collection, treatment, and
disposal and any other applicable rules and laws. If drainage or fill'requirements are spec~d:on
improvementpermi~ they must be made and inspected by this health departmentprior to construction
authorization issuance and system installation.
2. The wastewater system shall not be covered or placed into use until inspected by the Pamlico County Health
Department and an Operation Permit is issued. Any electrical components shall be inspected by the Building
Inspector prior to Operation Permit issuance and the system being placed into use.
3. Any alteration in site or soil conditions (including location, structures and appurtenances) or modification in
use, design wastewater flaw, or wastewater characteristics as specified in the associated Improvement Permit
and Application, may subject this Authorization and associated Pernut(s) to revocation. Such alterations
may result in the need of a site visit by this department resulting in an additional application and
associated fee(s). ~,
4. Improvements Permit and Authorization to Constructmust be on-site during inspection.
S. Other Conditions/Alternative Trench System Request:
OWNER CERTIFICATION
I certify that there have been no alterations in site (which may include change in home location, driveways, or water
supply - i. e. well vs. public water supply) or soil conditions or mod cations to facility, wastewater flow, or
wastewater characteristicsfrom those specked in the original application or associated Improvement Permit unless
authorized in writing by the Pamlico County Health Department. I also understand that airy such alterations,
mod cations, or false information are grounds for revocation of Permits and Authorization to Construct.
signature of Owner/Owner's Representative
NCDENR Authorized Agent

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MAR 1 C~r;S .~
Dale
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C\Documen~ and Settings\envhlthUAy Documents\form.pla 07-28-2008
. • 0. • PAMLICO COUNTY HEALTH DEPARTMENT
P.O. BOX 306
BAYBORO, N.C. 28515
,r. ,.,,,
,, ~ IMPROVEMENT PERMIT~~
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`Owner:Gaither A. Champion Jr.
wner Address:607 Old Friars Rd.
wner Address(2):Columbia, SC 29210 -
wner Phone #:[phone] ww
Property Address:75 Pecan Lane ~~ ~
.Property Address(2):Kennels Beach ~~
PIN:D091-57
Record #: ~ ~
`Establishment Type: Home
Type of Well: Public Well. ~~
Design Flow (GPD):360 ~
e
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s'- - a f
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~ c~mm~ccr~.v~~~o~
- % --

(~ XZD 0 yr J~G/7?
~, s- dr a d /~ ~ ~tia ~~u ~ 1
Repair Site _ _xo~~ra ~ 5' ~\ / d~a ~~GIT/ate
Wastewater System: Disposal Bed 8fl6°58~8" W X4.96
Long Term Acceptance Rate(GPD/SQFT):1.5
'Trench Width:3 FT --~-.~~T~;~'~ ~~~~
Trench Spacing (OC):3 F ~a ~'~1i°
Trench Bottom From NGL:-18 IN
,Septic Tank Volume:1000 GAL'
Place soil cloth over roc - ~ -, ~,.
~~ ~ 'a~ 'erg
Tbia Survey is of as Eiiating Parcel .° 3 ~ -~,
sad daea nar caste a new s#reet or "~'" ~" n = . ;,
CLan~ an eIiJ~1g 9tlt. Q~ ~„r. i Y _ - -
'Citia Snrv~y is aebjectta any facia -r ~~i,,.. ~~~ ~ •~t
that awry be disciosat by a #`a!i sud '~ ~ 5#1R'~ •"'
accurstc t3tk uars>~. `~'`f~~;~y~f9~~ •~' ~'r r
~~ ' AN AUTHORIZATION TO CONSTRUCT MUST BE OBTAINED AND
EIPiEuatTngTr°°~ .ALL FEES PAID PRIOR TO WASTEWATER SYSTEM INSTALLATION.
5Ii~ , $et ~ kips
_~ ..~.: y ate:,.
':I
THE PAMLICO CO. HEALTH DEPARTMENT RESERVES THE RIGHT
TO REVOKE THIS PERMIT IF THE SITE IS ALTERED, INTENDED
USE CHANGED, OR ANY INFORMATION IS FALSIFIED.
ANY CHANGES TO THIS PERMIT WILL REQUIRE A REDESIGN
PERMIT AND SUBSEQUENT FEE.
~~
NORM
~~
Authorized A ent: ,~ ~ ~ ,
g ~ /~~ ~ ~~ ~~~Z~" Date 1 /25/2006