162 Channel Ln HEALTH DEPARTMENT RELEASE For Office Use only
• *CDP File Number 2198267'_1
«sro Davie County Health Department
ra-r
5820940026,
210 Hospital Street County ID Number
P.O. Box 848
Evaluated For. NEW
Mocksville NC 27028
Phone:336-753-6780 Fax:336-753-1680 PERMIT VAUD 0 8 / 1 0 / 2 0 1 6
UNTIL
Applicant: Richard and Michelle Bell Property owner. Richard and Michelle Bell
Address: 162 Channel Lane Address: 162 Channel Lane
City: Mocksville City: Mocksville
State0p: NC 27028 State0p: NC 27028
Phone#: (336)528-5331 Phone#: (336)528-5331
Property Location& Site Information
Address162 Channel Lane Subdivision: Phase: Lot:
Road# Mocksville -- NC 27028
SINGLE FAMILY . Township:
*Structure: Directions
#of Bedrooms: 3 #of People: Hwy 601 North,right on Cana Rd. Left on Channel Lane, 1st driveway
on right
'Water Supply: PUBLIC
Type of Business
Basement: Yes a No
Total sq. Footage: No.Of Employees:
'Proposed Improvement:
'Release Conditions `
Attach new home to existing septic system.Mobile home is to be removed after CO is issued for new home built by True Homes. I
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? OYes ONo
Applicant/Legal Reps.Signatures *Date:
*Issued By: 2140-Nations,Robe *Date of Issue:_0 8 / 1 1 / .2 0 1 6
Authorized State Agent:
**Site Plan/Drawing attached.**
CQ Hand Drawing Olmport Drawing
HEALTH DEPARTMENT RELEASE
asTA1Fa Davie County Health Department CDP File Number: 219826 - 1
210 Hospital Street 5820940020
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 0 8 / 1 1 / x 0 1 6
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Scale: OBlock
Drawing Type: Health Department Release ON/A
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Page 2 of 2
APP ON FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
ti Davie County Environmental Health
n P.O.Box 848/210 Hospital Street
Sol l Mocksville,NC 27028
(336)753-6780/Fax(336)753-1680
Application For: ❑ Site aluation/Improvement Permit 9 Authorization To Construct(ATC) ❑ Both
Type of Application:Site
❑Re air to Existing System ❑Ex ansion/Modifcation of Existing System or Facility
***IMPORTANT***THIS APPLICATION CANMOTBEPROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed True Homes Contact Person Jackie Self
Billing Address 2649 Brekonridge Ctr Dr Home Phone (336) 992-2477
City/State/ZIP Monroe NC 28110 Business Phone (336) 992-2477
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
(Permit is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name Richard & Michelle Bel Phone Number (336) 528-5331
Owner's Address 162 Channel Lane City/state/zip Mocksville NC 27028
Property Address 162 Channel Lane, Mocksville, NC27028CityAdvance
Lot Size 5 acres Tax PIN# G40000000907
Subdivision Name(if applicable) Section/l ot# 1 SHEETS PROPERTY
Directions To Site:
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 1dNo
Does the site contain jurisdictional wetlands? ❑Yes itNo
Are there any easements or right-of-ways on the site? []Yes lallo
Is the site subject to approval by another public agency? ❑Yes ZNo
Will wastewater other than domestic sewage be generated? El Yes 9No
IF RESIDENCE FILL OUT THE BOX BELOW
#People 4 #Bedrooms 3 #Bathrooms 2 Garden Tub/Whirlpool ❑Yes ZNo
Basement: ❑Yes 1]No Basement Plumbing: ❑Yes Z7No
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business 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: RiConventional ❑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 system is intended to serve? ❑ Yes 2 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 permit ed hereafter are subject to suspension or revocation if the site is altered,the intended use
than , if the information submit . this application is falsified or changed I hereby grant right of entry to the Authorized
presentative of the Davie County Health D ent to conduct necessary inspections to determine compliance with applicabl(l
laws and rules. I understand that I am responsible the proper identification and labeling of property lines and corners aryd�Z,r
locating and flagging or staking the house/facility Iota ' n,proposed well location and the location of any other amenities.`U
Property ownE77
a Site Revisit Charge
Date(s): -
Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account#
Revised 11/06 Invoice#
.�, -• DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990005495 Tax PIN/EH#: 5820-94-0020
Billed To: Richard Bell Subdivision Info:
Reference Name: Location/Address: Channel Lane-27028
Proposed Facility: Residence Property Size: 5.01 acres
ATC Number: 5077 Site Type: Ggew-ORepair ❑Expansion
**NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie CountyEnvironmental
Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A ,
Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat
or the intended use change.
Residential Specifications: #Bedrooms ? #Bathrooms Z #People Basement❑Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size Type of Water Supply: P:ounty/City DWell DCommunity Well
System Specifications: Design Wastewater Flow(GPD)_.210 Tank Size 10M GAL.Pump Tank(V�GAL.
Trench Widthcc��3� Max.Trench Depth & Rock Depth/U�� Linear Ft. s (�?D,
Site Modifications/Conditions/Other. 00/0 Wtittva
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30—9:30a.m.on the day of installation. Tele hone#(336)751-8760.
Environmental Health Specialist Ith Date:-C �"-��C �
rerun i i mA ruP.,;CPa1
Davie County Healdl Deputinent
4�;6f Envirorunental Health Section J- ._ ,
P.O.Box 848
a 210 Hospit,-d Street ` 'g
O
Courier#:09-40-0G .19
j1
Mocksville,NC 27028
Phone:(336)-753-6780 Fax:(336)-753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Name: V idmoo �_ 22110 tllle Pell Phone Number (Home)
Mailing Address: J(g2 1,09 ✓�'J?� -A4 r-Ji 2;3 ,f (Work)
A4�'loc��s v,lCe NG o�70�j
Detailed Directions To Site: ��� TU ana Rd �G)/� �'�Jem Le -n
Cknnel Ln
Property Address: ll-o;-? Ch i nl7 i0- ( I_r► , o e(es v,' Ce /UC 8 70d`��►
lease FBI In The Following Information About The EXISTING Facility:
RIC�ard 7�'lr'C
Name System Installed Under. C4Ik &J/ Type Of Facility: n?obile A07y/
Date System Installed(Month/Date/Year): -1 /—O Number Of Bedrooms: Number Of People:, c -
Is The Facility Currently Vacant? Yes No If Yes,For How Long? -
Any Known Problems? Yes No If Yes,Explain:
Please Fill In The Following Information About The NEWFacility:
Type Of Facility: S i ni Number Of Bedrooms: 3 Number of People a-
Pool Size: arage Size: OI- Other:.
Requested By: ---- Date Requested: kr' I
(Signature)
For Environmental Health Office Use Only
Approved Disapproved
CsjkU_-_(L
. 9& 011114d !+
-� vl me
Environmental Health Specialist Date:
*The signing of this form by the Environmental Health Staff is in no way mtended,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#:
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