138 Brave Ln DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990003338 Tax PIN/EH#: 5871-71-9228
Billed To: James Tucker Subdivision Info:
Reference Name: Location/Address: 138 Brave Lane-27006
Proposed Facility Residence Property Size: .512 acres
ATC Number: 3863
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of
G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CONS -_UnCTTIION IS VALID FOR A PERIOD OF IVE ARS.
Environmental Health Specialist's Signature: ( Date: ; I, d t
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
has been installed in compliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and
Disposal Systems,"but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any
given period of time.
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Septic System Installed By: G��y
Environmental Health Specialist's Signature: " Date:
DCHD 05/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street �f—f� Or l
Mocksville,NC 27028 7
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990003338 Tax PIN/EH#: 5871-71-9228
Billed To: James Tucker Subdivision Info:
Reference Name: Location/Address: 138 Brave Lane-27006
Proposed Facility Residence Property Size: .512 acres
ATC Number: 3863
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of aseptic 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). THIS
PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type ,� #People #Bedrooms�� #Baths
Dishwasher: Garbage Disposal: ❑ Washing Machine Basement w/Plumbing:27"' Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste:
Z70
❑
Lot Size Type Water Supply Z"D Design Wastewater Flow(GPD) �� Site: New Repair❑
System Specifications: Tank Size I Oo/GAL. Pump Tank GAL. Trench Width 1&/ "Rock Depth �.2 Linear Ft,Z0
Other:
Required Site Modifications/Conditions:
IMPROVEI♦IENT/OPERATION PERMI LAYOUT- APPROVED ENT FILTER. RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Conta a represen t vie Co ty Health Department for final inspection of this
system between 8:30 a.m.to 9:30 a.m.or 1:00 pr.m. the day o 'n llation. Telephone#is(336)751-8760.****
�` , �1r,_Y_
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P / ✓
Environmental Health Specialist's Signature: awl Date: 1 l
DCHD 05/99(Revised)
8
D 0 WE
CATION FOR SITE.EVALUATION/IMPROVEMENT PERMIT&ATC
'EC EDavie County Health Department
Environmental Health Section
AUG 2 5 2004 P.O. Box 848/210 Hospital Street '
Mocksville, NC 27028
(336)751-8760
*** 1 *** THIS PPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be BilledL�l�'�Q Contact Person
/
Mailing Address / � /
/�.S 1�a4� &vq— Home Phone
City/State/ZIP /ri�/Q`�l ee—//V� C. p2M6 Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
!� 3. Application For: Site Evaluation �-Improvement Permit/ATC ❑ Both e
4. System to Service: L:YHouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. Type system requested: 0`-Conventional ❑ conventional modified ❑ innovative
6. If Residence: # People 2 # Bedrooms # Bathrooms Z�Z
126-ishwasher ❑Garbage Disposal MKashing Machine BBasement/Plumbing ❑Basement/No Plumbing
7. If Business/Industry /Other: verify type /V/ n # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
S. Type of water supply: M--County/City ❑ Well ❑ Community
9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes ANO
If yes,what type?
***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions: WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Tax Office PIN: # -6-1? // !7/100 00 U Z-6-V/ 742 `44%/�C-4f-
i gD�
Property Address: Road Name 13� i1dC L/l. �v.�/I ,�� Or►
City/Zip ✓c'l�^il'�,A C,
If in a Subdivision provide information,as follows: /'li/ � c�//-� i1 0.-7
Name:
Section: Block: Lot: Date home corners flagged: 1'- z 3"6?L�
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or if the information
submitted in this application is falsified or changed. I,also,understand that I am responsible for all charges hicurred from
this application. I,hereby,give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine the site suitabi Y.
DATE �"�i"�J V / SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed
property lines and dimensions, stru tures, setbacks, and septic locations).
Site Revisit Charge
Datc(s):
Client Notification Date:
EBS:
Sign given Account No.
Revised DCHD(05/03 Invoice No. �-