241 Cedar Creek Rd, DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
. Mocksville, NC 27028
(33G)751-87G0
Account #: 990002784
Billed To: Steven Pope
Reference Name:
Proposed Facility: Residence
ATC Number: 4507
Tax PIN/EH #: 5832-90-6783
Subdivision Info:
Location/Address: Cedar Creek Road-27028
Property Size: 1 aac
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLTST BE ISSLJED 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 perrnit(s) (in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature:
Date:
�,fo CERTIFICATE OF COMPLETION
�7
**NO��* The issuance of this Certificate of Completion shall indicate the system described on ImprovemenbOperation 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. _
� ►c,r� �+-sr� c�, �-� c�9�
�7�� `i� � t �7 -► `7
Septic System Instailed By:
Environmental Health Specialist's Signature :
DCHD OS/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
� Environmental Health Section
• •' • P. O. Boz 848/210 Hospital Street
' Mocksville, NC 27028
(33G)751-87C0
Account #: 990002784
Billed To: Steven Pope
Reference Name:
Proposed Facility: Residence
IMPROVEMENT/OPERATION PERMIT
Tax PIN/EH #: 5832-90-6783
Subdivision Info:
Location/Address: Cedar Creek Road-27028
Property Size: 1 aac
ATC Number: 4507
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction 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). 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 �7 #Baths �
Dishwasher: � Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 0
Lot Size Type Water Supply � Design Wastewater Flow (GPD) �� Site: New u Repair ❑
System Specifications: Tank Sizel��6 GAL. Pump Tank
Other:
Required Site Modifications/Conditions:
GAL. Trench Width � Rock Depth /� Linear Ft�
11�1PROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF fi " BELOW
FINISEIED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis
system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 130 p.m. on the day of installation. Telephone # is (33C►)751-87G0.****
ii�/4x � �'�P�C.0 �� ��C
3 G ��
a
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Environmental Health Specialist's Signature: Date: '2" ,�
DCHD OS/99 (Revised)
�\
.i i•
� s
`• �� APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Health Department
�� _
�, {� � � � Environmental Health Section
��`� �� � P.O. Box 848/210 Hospital Street
, 3 0 2006 w- '� Mocksville, NC 27028
� AUG � (336)751-8760/ Fax (336)751-8786
�_.
DA`11E
Pemut ❑ Authorization To Construct(ATC) �Both
�IMPORTAN2*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed S�('P�h tn ��.� � Contact Person
Billing Address % 2,�.�' /- �, -�/ Home Phone S.�� r i� �/c�C S�
City/State/ZIP �lI o� (ts�•.� / � i°�� c: Z� U z �� Business Phone � ; � �7 � � ,� � ! � �,
Name on Permit/ATC if Different than Above
Mailing Address
PROPERTY INFORMATION
City/State/Zip
NOTE: A survey�plat or site plan must accompany this application.
(Pernut is valid or 60 months with s�te plan, no expiration with complete plat.) /-y�-
Street Address �Q(/ �/��,(Zp�- City /%Jo���tS;,,; /l� Tax PIN# 5� 3�' ��— l�,�Is
Subdivision Name Section/Lot# Lot Size ,�, j� ��
Directions To Site: F4 �;,, ; n�(�,.._,. 7� -�-v �1��.-)cl ;.� ti �1 ��� r__ 1`2.�� 1 u�'it �; �� c�,�
�� t c��i: •- � ��t`(` � . �� %�o �� Zr-�"'� [i.�l ' ��Y`1T J .
Date House/Facility Corners„Flagged �"-�� � ��
If the answer to any of the following questions is "yes", supporting documentation must be attached.
Are there any existing wastewater systems on the site? ❑Yes ff�To
Does the site contain jurisdictional wetlands? ❑Yes �Io
Are there any easements or right-of-ways on the site? ❑Yes �.No
' i: Is the site subject to approval by another public agency? �Yes �No
•'� Will.wastewater othet than domestic sewage be generated? ❑Yes �No
IF RESIDENCE FILL OUT THE BOX BELOW
# People # Bedrooms # Bathrooms �... Garden Tub/Whirlpool ❑Yes y�No
Basement: Yes �9No Basement Plumbing: ❑Yes �No
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/B�siness Total Square Footage of Building # People
# Sinks # Commodes # Showers # Urinals
Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: # Seats
Type system requested: '�Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type:�( County/City Water � New Well ❑Existing Well ❑ Community Well �
Do you anticipate additions or expansions of the facility this� ystem is intended to serve? � Yes ❑ No
If yes, what type? � /.x�)�).��1 �j� -«irv��.r. /hE�r1 r`•x�,�,, u.n.S�� `�`_s
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that
any pernut(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if
the information submitted in this application is falsified or changed. I understand thnt I am responsible for all charges incan•red
fi-om this applicatio�i. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to
conduct necessary inspections to deternune compliance with applicable laws and rules on the above described property located in
Davie County and owned by > f����i� A,.,��?
Property owner's or owner
�'' �e� � ���
Date
Sign given ❑Yes ❑No
Revised 2/06
signature
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account # �76 �
Invoice # �7�`�
DEED TRANSFER CHECKE�
DAT� `.� -30 - 6 � gy`�'lt��� i�
- TAX ADMINISTRRTOr
Excise Tax: Gift Deed
BK611PG I 81
fILED fOR REGISTAATiON
AuQust 30, 2006 11:12 a.m.
DATE 71ME '
AND RECOROEOIN BOOK 6�� PAGE is�
M. BRENT SHOAF, REGISTER OF DEEDS
DAVIE COUMY� NCn A , �
BY �,;�c.r.a� �,.�/` JLC�,�,�,ei
Asst. •
Recording Information
Drafted by: Henry P. Van Hoy, II, Attorney at Law, Mocksville, North Carolina
Mail to: GRANTEES @ �� ��� �� �dl �/jQ'l�W�� (� � � l.� � V
�rL
TAX MAP: Part of Parce150.02, Tax Map D-5
WARRANTY DEED
THIS DEED made this � day of S�I , 2006, by and between EUGENE L.
POPE and wife, PATRICIA SUE POPE, the GRA ORS to STEPHEN EUGENE POPE and wife,
ERIKA POPE, the GRANTEES:
WITNESSETH:
THE GRANTORS, for valuable consideration paid by the GR.ANTEES, receipt of which
is acknowledged, have and by these presents do convey unto the GRANTEES in fee simple, all that
certain parcel of land situated in Farmington Township, Davie County, North Carolina (the
"Property") and more particularly described as follows:
TRACT 1 as shown on a Plat recorded in Plat Book 8, Page 385 in the Off ce of the
Register of Deeds of Davie County, North Carolina which Plat was prepared by
Tutterow Surveying Company, drawing no. 7306-3A and which Plat is incorporated
herein by reference.
THE GRANTORS acquired the property by instrument recorded in Deed Book 65.6, Page
552 of the Davie County Registry.
TO HAVE AND TO HOLD the Property and all privileges and appurtenances thereto
belonging to the GRANTEES in fee simple.
THE GRANTORS COVENANT with the GRANTEES, that the GRANTORS are seized
of the Property in fee simple, have the right to convey the Property in fee simple, that title is
y.
. � // -
:,, BKb11PG 1 88
� , .
%-mazketable and free and clear of all encumbrances, and that the GRANTORS will warrant and
'' defend the title against the lawful claims of all persons whomsoever, except for the exceptions
hereinafter stated.
Title to the Property is subject to the following exceptions:
1. Easements and restrictions of record.
2. Ad valorem taxes for 2006 and subsequent years.
�,
The terms GRANTORS and GRANTEES as used herein include the masculine and the
feminine, the singular and the plural, as the context requires, and the heirs, successors, and assigns
of the parties hereto.
IN WITNESS WHEREOF, the GRANTORS have signed this deed the day and year first
above written.
GRANTORS
,.,.._.� � • �'�-�-
EU ENE L. POPE
�r.��l�ri
PATRICIA SUE POP
STATE OF N TH CAROLINA
COUNTY OF Q�(JZ�,
I, a Notary Public of the county and State aforesaid, certify that EUGENE L. POPE and wife,
PATRIGIA SUE POPE, personally came before me this day and acknowledged the voluntary
executio of the f regoing instnunent. Witness my hand and official stamp or seal, this the ��
day o , 2006.
�����»naai►p� C� i � I v� �, ►' 1
' ,,,``����iiiti±� �j,,���',r' otary Public
�� � : -
= OQ ..�H Cj�, ,q4'1e� M
,��S:F'. '
My commission expires:� �� r. d e,� -
r � �� +
•
(Affix Official Seal) '�+�'���LjF ���,•`��`
.,, Ct�U� .+
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X:1MyFilesU-Iank Van Hoy�Iteal Estate�Pope, Eugene - Pope, Eugene, L. Gift Deed. mv 10194.8. Aug. 06.wpd
existing
�ron
CONTROL
CORNER
t from tha
vls(on cnd
members
cA not
her now or
�provais
3fora any
TRACT 2
��.,4�.�.� � . � << � �� ��.
INCLUDES S.R. i�34 R/W
iAKEN FROM
D.E. 65G, PG. 552
PL.BK. 8, PG. 303
COMPUTED BY D.M.D.
���
new
iron
existing
iron
TOTP,L= 300, 00
S 86• 12' 12• E—...s,...
TRACT 1
�.�.�� = 1. D 0 3 A C.
INCLUDES S.R. 1434 R/W
TAKEN FROM
- C�. B. 656, PG. 552
PL.BK. 8, PG. 303
COMPUTED BY D:M. : - � --
_ ._.__- ._ ..
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' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil / Site Evaluation
APPLICANT INFORMATION
Account #: 990002784
Billed To: Steven Pope
Reference Name:
Proposed Facility: Residence
PROPERTY INFORMATION
Tax PIN/EH #: 5832-90-6783
Subdivision Info:
Location/Address: Cedar Creek Road-27028
Property Size: 1 aac Date Evaluated:
Water Supply: On-Site Well Community
Evaluation By: Auger Boring Pit
HORIZON II DEPTH
HORIZON III DEPTH
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE:
Public
Cut
OTHER(S) PRESENT:
REMARKS:
LEGEND
L�ndscape Pnsition
R- Ridge S- Shoulder L- Linear slope FS - Foot slope N- Nose slope
CC - Concave slope CV - Convex slope T- Terrace FP - Flood plain H- Head slope
T�Ctur�
S- Sand LS - Loamy sand SL - Sandy loam L- Loam SI - Silt
SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam
SC - Sandy clay SIC - Silty clay C- Clay
.ON�IST .N .E
a'IQ1St .
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely frm
�
NS - Non sticky SS - Slightly sticky S- Sticky VS - Very Sticky
NP - Non plastic SP - Slightly plastic P- Plastic VP - Very plastic
Structure
SC - Single grain M- Massive CR - Crumb GR - Granular ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
Mineralogv
1:1, 2:1, Mixed
1Y�
Horizon depth - In inches
Depth of fll - In inches
Restrictive horizon - Thickness and inches from land surface
Saprolite - S(suitable), U(unsuitable)
Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less
Classification - S(suitable), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gaUday/ft2 DCHD OS/OS (Revised)
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SITE EVALUATION/IMPROVEME�
Davie County Health Department
Environmental H�alth Section
P.O: Box 848/210 Hospital Street
Moc {s '1 e, NC 27028
( 36)751-8760/ F x (336)751-8786
For: ite Evaluation/Improvement Permit
TANT*** THIS APPLICATION
TION IS PROVIDED. Refer to_
APPLICANT INFORMATION
�i ATC 4
�G�
Authorization To Construct(ATC) ❑ Both
PROCESSED UNLESS ALL OF THE REQUIRED
�TION BULLETIN for instructions.
Name to be Billed� ��� ���`{-(� 5 Contact Person a.J�. �'�y ��Ii✓1���
Billing Address ;� c ,� .9� C�L C� � Home Phone �j �`i ��,�"��
City/State/ZII' �5 �LL� C Z70Z�� � Business Phone
Name on Permit/ATC if Different than Above
Mailing Address
PROPERTY INFORMATION
City/State/Zip
NOTE: A survey plat or site plan must accompany this application.
(Pernut is valid for 60 months with site�lan, no expiration with c mplete plat.) '/
Street Address � �� �' L= j�f}�j� � � � �� City ; -✓ � LL Tax PIN# �k � Z '�I � �Z�7
Subdivision Name Section/Lot#,� Lot Size
To Sit�,: L—
�Xir �
Date House/Facility Corners �'lagged ,3-3 U(o
If the answer to any of the following questions is "yes", supporting documen�ati�on �ust be attached.
Are there any existing wastewater systems on the site? ❑Yes ❑No
Does the site contain jurisdictional wetlands? ❑Yes C'(�10
Are there any easements or right-of-ways on the site? ❑Yes C�o
Is the site subject to approval by another public agency? ❑Yes B�o
Will wastewater other than domesric sewage be generated? ❑Yes �o
IF RESIDENCE FILL OUT THE BOX BELOW
# People # Bedrooms # Bathrooms Garden Tub/Whirlpool ❑Yes C4�d'o�
Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of FacilityBusiness Total Square Footage of Building # People �
# Sinks # Commodes # Showers # Urinals
Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: # Seats
Typesystemrequested: ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Oth�r
Water Supply Type��1 County/City Water ❑ New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes �l No
If yes, what type? � �
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that
any pernut(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if '
the information submitted in this application is falsified or changed I understand that I am responsible for all charges incurred
from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to
conduct necessary inspections to detern�u 1e complia with applicable laws and rules on the above described property located in
Davie County and owned by �J 2/2..(.1 �I��.S
"� ? '—'�� Site Revisit Charge
P pe owner' o owner's legal representative signature
Date(s):
� U " Client Notification Date:
,�,�_� .
Date EHS:
Sign given ❑Yes ❑No Account # U/V
Revised 2/06 Invoice # �
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3099
D50000005002
5832818204
(51.35A)
8204
2032
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� DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil / Site Evaluation
APPLICANT INFORMATION
�c�-( � � 4v��c� �i�
�%ll�� �� � ����� �'a�/�s
P�aose�'����/�� - ��sic�e<i�P
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Water Supply: On-Site Well Community
Evaluation By: Auger Boring Pit
FACTORS 1 2 3
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTAN
SITE CLASSIFICATION: �
LONG-TERM ACCEPTANCE RATE: �
REMARKS:
PROPERTY INFORMATION
%r DIN� ��32 ��r-�Z��
��l'r�iOY� - ���Q � C���ee,� �'d:
4
EVALUATION BY:
Cut
5 6 7
OTHER(S) PRESENT:
LEGEND
L�ndscaue Position
R- Ridge S- Shoulder L- Linear slope FS - Foot slope N- Nose slope
CC - Concave slope CV - Convex slope T- Terrace FP - Flood plain H- Head slope
T�cturg
S- Sand LS - Loamy sand SL - Sandy loam L- Loam SI - Silt
SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam
SC.: Sandy clay SIC - Silty clay C- Clay
.ONSIST .N . .
aZ41Si
VFR - Very friable
�
NS - Non sticky
NP - Non plastic
FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
SS - Slightly sticky S- Sticky VS - Very Sticky
SP - Slightly plastic P- Plastic VP - Very plastic
,�tT]1sL11�
SC - Single grain M- Massive CR - Crumb GR - Granular ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
J
Mineralogv
1:1, 2:1, Mixed
lYQtr�
Horizon depth - In inches
Depth of fill - In inches
Restrictive horizon - Thickness and inches from land surface
Saprolite - S(suitable), U(unsuitable)
Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less
Classification - S(suitable), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gaUday/ft2 DCHD OS/OS (Revised)
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- DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil / Site Evaluation
APPLICANT INFORMATION
Account #: 990000810
Bilied To: Jerry Banks
Reference Name: Jerry Banks
Proposed Facility: Residence
PROPERTY INFORMATION
Tax PIN/EH #: 5832-81-8204
Subdivision Info:
Location/Address: Cedar Creek Road-27028
Property Size: 150 x 250 Date Evaluated:
Water Supply: On-Site Well Community
Evaluation By: Auger Boring Pit
FACTORS 1 2 3 4
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
EVALUATION BY:
Public
Cut
5 6
OTHER(S) PRESENT:
LEGEND
L.�ndsca�e Position
R- Ridge S- Shoulder L- Linear slope FS - Foot slope N- Nose slope
CC - Concave slope CV - Convex slope T- Terrace FP - Flood plain H- Head slope
Texture
S- Sand LS - Loamy sand SL - Sandy loam L- Loam SI - Silt
SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam
SC - Sandy clay SIC - Silty clay C- Clay
IYIQIS�
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Ex[remely frm
�
NS - Non sticky SS - Slightly sticky S- Sticky VS - Very Sticky
NP - Non plastic SP - Slightly plastic P- Plastic VP - Very plastic
Structure
SC - Single grain M- Massive CR - Crumb GR - Granulaz ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
7
MineralQgv
1:1, 2:1, Mixed
LY41�S
Horizon depth - In inches
Depth of fill - In inches
Restrictive horizon - Thickness and inches from land surface
Saprolite - S(suitable), U(unsuitable)
Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less
Classification - S(suitable), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gaUday/ft2 DCHD OS/OS (Revised)
9
Davie County Health Department
Environmental Health Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760/ Fax (336)751-8786
_ March 10, 2006
Mr. Jerry Banks
309 Cedar Creek Road
Mocksville, NC 27028
Re: Cedar Creek Road
Tax Pin #: 5832-81-8204
Dear Mr. Banks
As requested, a representative from this office visited the above site March 9, 2006, to
perform a site evaluation. Based on the information provided on the Application for Site
Evaluation and after the evaluation was completed, the site was found to be provisionally
suitable for the installation of an on-site sewage disposal system.
This Improvement Permit DOES NOT authorize the construction of a wastewater system.
An Authorization To Construct a wastewater system must be obtained from this offce prior to
the construction/installation of a wastewater system or the issuance of a building permit (in
compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement
Permit is subject to revocation if site plans or the intended use change.
Improvement Permit
System To Serve: ��1,� Wastewater Design Flow: ���
System Type: [�t;onventional ❑Accepted ❑Innovative ❑Alternative ❑Other
System Location: C,%�C/fftZ �i2 E� K(i�. Valid: C�'S Years ❑No Expiration
Site Modifications/Permit Conditions:
ps-i.p.letter 2/06
� � �
Specialist �/ Date