444 Allen Rd HEALTH DEPARTMENT RELEASE For Ice Use Only
t *CDP File Number 123191 -1
Davie County Health Department H3-0o0-00-101-01
210 Hospital Street County ID Number
x P.O. Box 848 Evaluated For. HDR/WWC
•-�' Mocksville NC 27028
Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID 0 9 / 1 7 / 2 0 1 3
UNTIL:
Applicant: Steven c. Beadle Property Owner: Steven c. Beadle
Address: 444 Allen Road Address: 444 Allen Road
City: Mocksville City: Mocksville
StatelZip: NC 27028 StatefZip: NC 27028
>Address444
hone#: (336)480-4527 Phone : (336)x#80-4527
Property Location&Site Information
Alle�Roa Subdivision: Phase: Lot
le- NC 27028
SINGLE FAMILY Township:
*Structure: Directions
#of Bedrooms: 2 #of People: Hwy 601 N,lefrt on Allen Road,Last house on right.
'Water Supply: WA
Basement: FiYes F1 No Type of Business:
Total sq.Footage: No.Of Employees:
'Proposed Improvement:
Building 44x20
'Release Conditions
It is the responsibility of the owner to maintain a 5'minimum setback between the wastewater system and any part of the structure
foundation,including porches,decks,and any other appurtenances. If you are unsure as to the exact location of the septic system,please
have a licensed installer or inspector locate the septic system for you. The local county health department in no way implies that the
proposed construction meets the required setbacks from the septic system unless otherwise noted. This release only shows that this
property has an approved wastewater system that appears to have met the permitting requirements at the time it was installed.
This release in no way expresses or implies that the existing subsurface sewage treatment and disposal
system serving the site will continue to function for any period of time.
Applicant/Legal Reps.Signature Required? QYes ONo
ApplicantfLegal Reps.Signature-, *Date:
*Issued By: 2244-Daywalt,Andrew *Date of Issue:_ 0 9 / 1 7 / 2 0 1 3
Authorized State Agent:
**Site Plan/Drawing attached.** TotalT1me:(HH:MM)
0 1 Hours 0 0 Minutes
O Hand Drawing 0 ImportDrawing
Davie County Health Department
Vj� Environmental Health Section
P.O. Box 848 1
RECEIVED 210 Hospital Street ��
O Date: �_ Courier# : 09-40-06
Mocksville, NC 27028
Phone:(336)-753-6780 Fax:(336)-751-8786
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) Replacement Remodeling Reconnection
Name:_q4-e.y-ei1 C 1,,'ead` e— Phone Number(�.� � � SD q � (Home)
Mailing Address: 9 Y `-1 kkL x r. P,10 5 Cc A, (Work)
OG�'1 SV► 1I t N(9'7 0r� Email �tciG�lt�'Rh (h S /1/G�oD .GQk.ti
Detailed Directions To Site: 6,Q ( All C K !!� �LL c� '`� G k 5'�
WS-006-00- 101-0/
Property Address: Ci V". G
Please Fill In The Following I1n'formation.About The EXISTING Facility:
Name System Installed Under: T Y't e' Type Of Facility:
Date System Installed(Monthffiatc/Year): ge_,V4zn*
umber Of Bedrooms: f— Number Of People:
Is The Facility Currently Vacant? Yes No If Yes,For How Long?
Any-Known Problems? Yes No If Yes,Explain:
Please Fill In The FpRowing Information About The NEW Facility:
Type Of Facility:**Bl )O t "Lt IV OkaNumber Of Bedrooms- umber of People
Requested By: Date Requested: - 3
(Signature)
For Environmental Health Office Use Only
Approved Disapproved
Comments:
Environmental Health Specialist Date:
*The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee
(extended or limited)that the on-site wastewater system will function properly for any given period of time.
Payment: Cash Check Money Order # Amount:$ Date:
Paid By: Received By:
Account#: Invoice#:
.. J. - ri..,. ..,h .....+, Y nb. p K I > v i .. -', s I ...,...., •O: +�,_�4 ..
AUTHORIZATION NO: (j A DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee's 1 P.O.Box 848
Name: ! ' «J� '`I�U �L' j"l f Mocksville,NC 27028 Subdivision Name:
Phone#, 336-751-8760' '
Directions to property: `�1? �4� Section: Lot:
/ n/ AUTHORIZATION FOR - -
G6 !r � �� 'r� WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION
Road Name: zip: O
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits:This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.,
(In compliance with Article 11 of G.S.Chapter 130A.Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
t''�G`I y''l y`<t r`✓ �P` IS VALID FOR A PERIOD OF FIVE YEARS. 6
ENVIRONMENTAL HEALTH SPECIALIST` DATE ISSUED -
-
• �� 6 3 7A DAVIE COUNTY HEALTH DEPARTMENT
yY
' IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
` et
rmi
Namtee's
..l / I= - • :� Subdivision Name
i
Directions to property: - /'/ /raG-cJ Section: Lot:
PIMPRST _ -
�p,,,, Tax Office PIN:#
Road Name: ���G/J/�� Zip: ,:?r
**NOTE**This Improvement Permit DOES NdT authorize the construction or installation of a septic tank system or any wastewater system.An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
ji
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILbf G TYPE #
—F-� BEDROOMS�#BATHS_I--#OCCUPANTS V_GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLEISHIFT I #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) -- NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH S16 ROCK DEPTH 49- /LINEAR FTQ?eZ
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT*RPPROVED EFFLUENT FILTf: ISI=R(S) IF 6TBELOW FINIS}IED GRADE*
r-
,.t
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#1$;{�q¢kl61yglm.
OPERATION PERMIT
SYSTEM INSTALLED BY: l�/yfl
1
AUTHORIZATION NO., ✓�X OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE "
WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NOWAY BETAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96(Revised)
*•��;,+'`..K•a,rs•sS.,. k .�-f s .n;;.� ,, `'.:,; w..,w r�; e,,,.-'i F "�+'b,,r .,y« P -'4;,' i a - ,. r� ,>, {
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittee's
Name:« »�• �' f= Subdivision Name.
x Directions to property: A).,r, r Section: y Lot:
- IMPROVEMENT
PERMIT Tax Office PIN:# - -
Road Name: /f�� ii Zip: 1
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.An
AUTH9RIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit.
(In compliance with kdcle 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
f
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
. ;'• t: PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEAL'T'H SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
y INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:.BUILDING TYPE _ #BEDROOMS_ #BATHS_�#OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WAITER SUPPLY �( DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE y
SYSTEM SPECIFICATIONS;,TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ��
ROCK DEPTH ,LINEAR FTC ��k:L.C�L
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: �i
f i
IIIPROVEMENTPERMIT LAYOUMAPPRDVED EFFLUENt FILTE RISER(S) IF 61' BELOW FINISHED GRADE;
r
\;*CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#I9x,104XWj87b0.
�! (335)751—$761
L
OPERATION PERMIT
SYSTEM INSTALLED BY:
AUTHORIZATION NO., '41� PERATION PERMIT BY. DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NOWAY BETAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96(Revised)
1
` DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APP CATION FOR IMPROVEMENT PERMIT(REPAIR)
�T/
NAME �� < <-� w C S' PHONE NUMBER
ADDRESS / �� ��/�UGK �/���`` Al. SUBDIVISION NAME
LOT#
DIRECTIONS TO SITE /All"') �Cl " 4�5011y ���Y At —Allej,✓-
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY /-/ /NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY / SPECIFY PROBLEM OCCURRING
DATE REQUESTEDhz�__ INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge,and that I understand 1 am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1(93
�yr /a22