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696 Cedar Creek Rd : HEALTH DEPARTMENT RELEASE U Davie County Health Department Environmental Health Section County IDNumber 210 Hospital Street rr , Evaluatedn,For r Mocksville, NC 27028 , Phone:336-753-6780 Fax:336-753-1680 HORIWWC Permit Valid Until: 05/01/2019 Applicant: Robert Ernest Property Owner: Donald Wayne Smith Address: 5904 Arden Drive Address: PO Box 428 City: Clemmons City: Mocksville State/Zip: NC / 27012 State/Zip: -NC / 27028 Phone #: Phone #: Property Location & Site Information Address: 696 Cedar Creek Road Subdivision: Phase: Lot: Road#: Mocksville NC 27028 Township: *Structure: BUSINESS # of Bedrooms: # of People: Directions:Hwy 158 To Farmington Rd. turn left on Farmington go to intersectin at Hwy 801 turn left Cedar Creek Rd on Left. *Water Supply: N/A Type of business: Basement: ❑ Yes EX No Total sq. Footage: No. Of Employees: *Proposed Improvement: Air Soft Field *Release Conditions: **Site Plan/Drawing attached.** Total Time:(HH:MM) OHand Drawing OImport Drawing Hours Minutes Activity Code: HEALTH DEPARTMENT RELEASE �r a4�: Davie County Health Department e su Environmental Health Section aC3Ejit ID Number � ' 210 Hospital Street ' Mocksville, NC 27028 "Ebaluated, HORNNNC �' Phone:336-753-6780 Fax:336-753-1680 Permit Valid Until: 05/01/2019 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? FlYes ❑No Applicant/Legal Reps. Signature: *Date: *Issued By: Nations, Robert *Date of Issue: 05/01/2014 Authorized State Agent: gas, 0429 .4 **Site Plan/Drawing attached.** Total Time:(HH:MH) OHand Drawing OImport Drawing Hours Minutes Activity Code: r' } Davie County Health Department '91836 Environmental Health Section ,... + "CENED P.O.Box 848 2, 210 Hospital Street Cp h �� Dam 2 Courier# :09-40-06 Mocksville,NC 27028 Phone:(336)-753-6780 Fax:(336)-753-1680 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection ? Name: rho '� z5A- Pe T Phone Number. c33Co 91�7 d., 2 1 (Home) Mailing Address:-S'-�i0'VAMA- �'�' - ----- (Work) 2,WIZ, Email Address: Detailed Directions To Site: 914/V 201 MA-rd C&ar ,t'CPkn d- Property Address: r _K ee U! r- Z7f3 Z1� Please Fill In The Following Information About The EXISTING Facility: \ Name System Installed Under. S&J( 2 A/ bUAIAl Type Of Facility:-51AQ& jr1 ide snob./e �/onre Date System Installed.(Month/Date/Year): 71A2 /.Z Number Of Bedrooms:__a2_Number Of People: o _ Is The Facility Currently Vacant? Yes ®o If Yes,For How Long? Any Known Problems? Yes ®o If Yes,Explain: Please Fill In The Followi g I ation Abo t e NEW Facility: `Z Type Of Facility: s;ne umber Of Bedrooms: Number of People Pool Size: Garage Si Other- Requested By: Date Requested: (Signature) For Environmental Health Office Use Only Ap rove Disapproved C ents: 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#: Z N� � �✓oay S�7! C�l w io�r v 7- C) L SEpflG os � FRONT � S� d 6vir���I �W )Orv°j -,(aaa� ,+��a� Ob �(- h.i:,-i a yK\N;w`�i„�:�„t <.,a"h'i 5.} ',nT,'.Y*�yN �''�ti�,. sv Yt �v n,,.h2 w �t� i,�i>'-C +, .,f r ,--1 z-t�1• �-;` ,t'- axq ai() S' }� K. Aa : o1112AZION NO,.; 01 3q :DAME COUNTY HEALTH DEPARTMENT., Z = Environmental Health Section C!1'ERTY INFORMATION . Permittee¢ / P.O:Box 848 Name: Mocksville,NC 27028 Subdivision Name: /7 J # 336-751-8760 Directions to property fy 'c '/�i`i.' ( � %�: c Section:. Lot: ,�j AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION Road Name. Zip: **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie CountyEnvironmental 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 I 1 of G.S.'Chapter 130A;Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) r ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION �'��'� /- t!G- IS VALID FOR A PERIOD OF.FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED .. � .y ,-a.n.,r �p-- ' �r ',�.'Y' .. ,:y s t -4 V a• t ♦ _ w .y' ;a_ � _.. *.r"..-k ♦ '"o.; t d :M., ,. 3 DAME COU .TY HEALTH DEPARTMENT _ IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Name: ��t � :1`!( ' +- /y�• ` % Subdivision Name: Directions to property: `f s �% ' ' F Section: Lot: IMPROVEMENT ;f,f��•, ' ; ;`,•;/ v PERMIT Tax Office PIN;# Road Name: Zip:' **NOTE**This Improvement Permit DOES NOT 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 constructionfimstallation 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) r ***NOTICE / ***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE. d ��;_, - i� � ' r, . �; 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: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 WATER SUPPLY DESIGN WASTEWATER FLOW(GPD NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZEGAL. PUMP TANK_ GAL. TRENCH WIDTI(_r—t- ROCK DEPTHLINEAR FT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAyouTAPPROVED EFFU1ENT FILTER* *RISER(S). IF 6" BELAY! FINISHED .(3RPD'E* r **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M.O ON THE DAY OF INSTALLATION.TELEPHONE#I � g0. (336)751-8760 OPERATION PERMIT S)N3TENJ INSTALLED BY: ASI ©r y-looV-S Of dTCr O� AUTHORIZATION NO. -OPERATION PERMIT B DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT fEM DESCRIB OVE 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. DCHD 05/96(Revised) /' :. , �• _ DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) NAME �O /�Q-Lc� �hr�-Jl-� PHONE NUMBER ri ADDRESS l Q`I' C� ( o �_ ��Q�ieo� SUBDIVISION NAME 9Gl�S� ✓ r�Le. r -�- LOT # DIRECTIONS TO SITE di DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING f� DATE REQUESTED SZ=&-0 NFORMATION TAKEN BY I4- (`t This is to certify that the information provided is correct to the best of my knowledge,and that I understand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev.1193