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746-748 County Line RdDAVIE COUNTY HEALTH DEPARTMENT r • Environmental Health Section P. O. Boz 848/210 Hospital Street , ' Mocksville, NC 27028 (336)751-87G0 � 3 - 2w- dl IMPROVEMENT/OPERATION PERMIT 1� --� � Account #: 889900631 Tax PIN/EH #: 4799-86-9137 Billed To: Robert BrBcken Subdivision Info: Reference Name: John Bracken Location/Address: County Line Road-28834 Proposed Facility: Residence Property Size: 54 Acres ATC Number: 2123 **NOTE** This ImprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AiTTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained'from this Deparhnent 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 PERMTT LS SUBJECT TO REVOCATION IF SITE PLANS OR T�IE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMTT BEFORE INSTALLING SYSTEM. J Residential Specification: Building Type � �� #People � #Bedrooms �� #Baths � 2 Dishwasher: � Garbage Disposal: ❑ Washing Machine: la' Basement w/Plumbing: 0 Basement/No Plumbing: � Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size ��� Type Water Supply `�/'tl� Design Wastewater Flow (GPD) �,e�',� Site: New �Repair ❑ System Specifications: Tank Size��GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width �' Rock Depth � Linear F��a � IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6" BELOW FINISHED GRADE. ****NOTICE: Contact a r resentative ofthe Davie County Health Department for final inspection ofthis system between 8:30 a.m. to 9:30 a.m. or I:O�p.n%to 1:30 p.m. on the day of installation. Telephone # is (336)751-87G0.**** Environmental Health Specialist's Signature: / v� �(� Date: ��.��� � DCHD OS/99 (Revised) Account #: 989900631 Billed To: Robert Bracken Reference Name: John Bracken Proposed Facility: Residence ATC Number: 2123 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-87G0 Tax PIN/EH #: 4799-86-9137 Subdivision Info: ��W' / . �t71 V Cn1 � �/ _ .�/ Location/Address: County Line Road-28634 Property Size: 54 Acres 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 WASTEWAT CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health SpecialisYs Signature: , � ,, Date: �j�/�� . CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall in te the system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S. apter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken a gua ntee that the system will function satisfactorily for any given period of time. � �� �� Septic System Installed By: Environmental Health Specialist's Signature r v �U Date: "�� � DCHD OS/99 (Revised) � . � ��� �� . ..��� � 7'��g � APPL�CATION FOR SffE EVALUATION/IM�ROVfMEM PERMff & ATC D i�avte i.c�nty liealth Department S�� Fnvironmenk'a/Hea/thSe�ction P.o. aox �as/Zio xo8pit� stxeet O �/ � � Moc:ksnilie, xc 27028 � � / ` .q � �i�� y��C (336) 751-8760 S' r%� \ 11� +�'x*2MPORTANZ"A'** '1�iiI3 l�P�,'.+ICi+TI0,4� C.Aii�'NOT BE PROCESSED UNLE33 ALL THE REQIIIRED iNFOF�TION I3 ?ROVID�. Refer to �hhe INFORt�,TION BULLETIN for instructions. 1. xam. to b. 9ill.a p n e r�- I�.��n� l�r�1 C,� contaat r.rsoa ,'��/jn %r4r /�'en Ma.a linQ Irddr�ss '/ c.I Qi � ['�u� �-U I �f� °L /l � . Ho� ?hona �/ � � - � u � (A �— T Ci�y/stat.o/Zip ��9fml�flC.l �v,�. 25�3�1 Husinesa Bhona 2. Na�s on 8ormit/ATC if Dilfarant than Abovo Msillnq 11ddr�as City/Stato/Zip - 3. Appiication For: 0 3ite Enaluatioa ❑ Impronemsnt Permit/ATC C� Both a. , syst..m to s•�soo: ❑ i3ouse SYMobile Home ❑ Business ❑ Industry ❑ Other s. �� �cc�iaence: � Peopla ___�__ # Bedrooms �_ � Bathrooms r jz, ❑ Dishraahor O GarbaQ� Disposal �ashiaq Machina 0 Sasomant/Plumbinq ❑ Has�at/No Plumbinq 6. S! Businoss/3ndustry/�thor: Spacify typ� �?ooplo � Siaks i Co�odos � Shoxars � Urinals # Nater Coolors IiT FOODSER�I�CE: #�eats Estimated Water Usage cQ�loas p.r dag) 7. '1`ype of pater supply: C+�County/City ❑ Well ❑ Commusiity e. Do you anticipate add�tions or eapansions of the facility this system is intended to serve7 0 Yes �No If yes, ��vhat type? - -- -- ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROP�RTY INFORMATION REQUESTET� BELOW. Either a PLAT or SITE PLAN MI/ST BE SUBMIY'TED by the clieLt witL THIS APPLICA'Y'ION. Property Dimensicins: S��i /�� _,� �Caa Office PIN: # L� 7 9�- �s� '�1 I 3'7 �'�•;aiperty �:4dress: Road Name i� oc..�' n%4 1; a� e%� City/ZIp %��yrrnDn i/ ;.�-�l03�% If in a�'abdivision provide information, as follows: Name: u�e :tion: Block: Lot: WltITE DIREGTIONS (from Mocksville) tu P�30PER7i 1: �O � +O W q r cl S-�a �u> l l e -�4/n �■ �� ►. � L� .�. . • . C • . . .• �. �'. Date Property Fiagged: (o �l4 � �7 �'his is to certify that the information provided is correct to the best of my knowledge. � anderstand that any permlt(s) �ssued hereafter are subject to saspension or revocation, if the site plans or intended use change, or if the inf�rmation sabrmitted in this app.ication is falsified or chn�gad I, also, understand that I am responsible for all cA;arges incurred jrom thJs applicatdon. I, hereby, give consent to the Aathorized Representative of the Davie County HealtL Department to enter apon above described property located in Davle Couuty and ovrned by 3r,1�,r-� %�,r c� ,�'� to conddct all testing p;•ocednres as nece.ssary to determine the site snitability. DATE Co - � $ - 9 �T SIGNATURE g��T.n .���, _._ THIS AREA MAY BE USETi FOR DRAWING YOUR SITE PLAN (Inclnde all of the fo�!�;•�ving: E�t�.i� and pr�?. ��nsed property lines and dimensions, stractares, setbacks, and septi�, iocationsf. � � ��� �� �� ,s S� C� , f� � �(� ,��� '� S �� S� RevEsed IDCHD (07/99) 3lte Revisit Charye�� Date(s): � Client P1otIfication Dritet � � ��HS: _ � Accouat Pa1a 3 / Invoice No. lJ ��/ , _ _ _ _ _ _ , -- --- - - . � � � � � � �� I � �� x605. 9G � ` � � 081.08 ; ��� i�.."� � � -` � � � ��� �,y�' �`°' �� �� � ���: _ � , - F � � � �. .-• � � � ���� � _ a� � � e� � . � `* � a ` d .n E � . � � �'� .� � � . '� a,x : .� �_ . � ._m. .`N+"�� . #��i .i � . a �z a �. �," .. ' � : `i' . � . r �' i .t +. s , . c� _ � p {� � o�s^ � Si t� ��8. �/ �� � . . � 7 a- � � / � � s % � . � �� I 9.5 �A � �� "" � �� � � � � �' � '` 2 I A ,�. 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Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gaUday/ft2 ►�.,• _ � •�CE',.h ;Revised CS/99} ■■ ■■ ■■ ■ ■ ■ ■ ■�■ ■�■ ■�■ ■���■ ■■ ■■ ■■�■��■■���������■���■������■��■���■�■■�■�■■�■����■�■■■�■■■��I ■■�■��■■�����■���■�����■■■■■ ■������■■�■�■������■■■■■�■■■■��I ■■�■■�■����■■�■■��■��S■■■�■��■�■����������■�����■■■■��������I ■�■■����■■�■■■���������■�����■■���■��■��■�■�������■■��������■I ■��■�������■■■�■������■������■���■■��■��■■■■���■���■���■■�■��I ■■��■■�������■�■����■■�������■r��■�■■�■��������■����■�■��■■��I ■■����■�■■■������■■��■■■■����■�■���■���■�����■��■■■���■����■■I ■�����������■■��■��■���■■■�■��■■���■■■�■�■■�■��■��■�■�������■I ■�■�■■���■■�■■���■��■■�■■�■■���■���������■e�������������������� ■�■ ■�■ ■������■����■■���■■�����■ ■���■�������■��■■�����■�■■N���■ ■�■■■�����■���■�������■����■��■�■���■■■■�■���������■■■��■■ ■������■�■■��■���■■■■������■�■������������■■���■�������■�N ■��������������■��■■■�■■�����■���������■■����■■■��■���■■��■ ■■■��■■���■■■���■■�����■��■■�■�■����■■■�■■■�������■���■���■ ■■■■■�����������������■�■��■���������■�����������■���■��■�■ ■���■�■■����■��������������■■��■�■■�������■������■■��■■��■■ ■������■��■��■���■A���■���■■■■�■��■■���■�����■���■��■■■■�■■ ■■�■■�■■�����■����\►��►.����■��■�■■��■��■■��������■��������■ ■■�����■■�■■�■����i�v■■�■ ■■�■�■■������■■�����■��■■����■■■ ■�■■■������■■■���■■■■■�����■■����■■���■■■����■■■��■����■��■ ■■��■���■��■������■■�������■■■���■■■���■■�����■■�■■�■�����■ ■■����■�■�■���■■■■■�������■■■�����■■�■■■�■��������■■■�■���■ ■■�■�■����������������■�����■■■■���■������■������■■■■��■��■ ■■�����■■■■■�����■■■�■�■���■���■■������■���■���■�������■■■■ ■■����■�■■■■�■����■■■■�■�■�������■��■■��■���■����■■�������■ ���������������������������������������������������������� ■��■�■■r��■�����������■■■��■■������■������■■��■■���������■■ ■��■■■�■■��■����■■��■�������������■�■��■■�■■������■�������■ ■■■�■■������■■■���■��■■■■■�■■����■■��■�����■■■����■��■■■��■ ■��/�■■��■■����■■�■■G��i::�:i■�■ii�����■■■���������■�■■■��■ ■���������■■�■��■A�■■■■■■■■■���■■■■11�������■�■����■■���■■■■ ■�■■■■■��������■�I�����������■■■���■I�■■■■■����■��■��■■��■��■ ���������������I���������������I��������������������� ■■�■�■�■�������■�11■��������������■�'���������■�■��■■■■■■■■�■ ■���■■�■■■�■�����11■■■n■■�■■����■��■■■�■■������������■�■��■ ■�■■����■��������i�■���■��■■■��■����■��■■�■����������������a ■■������■�������■��■����t�■■■��������■■■�■■■■�������■■■�■■�■ ■■��■■■������■■■■i���������������■����■■■■�����������������■ ■■��■�����������■c�■■■■�_=�::::��■�i��■�■■�■■■������■�����■■ ■����■��■■���■■■■c���—■�■����■■���■■���■�■�■■■���■■�■■■■���■ ■■■�������������■�■■■��■■ ■■�����■������■■�■�■■■■��■■��■�■ ■�■�����■■�■��■��■��■�����G�1���■��■■��■���■■�����■��■■�■■�■ ■t�����■■■■■������������■��a�■■■■■�■■■�■���■■��■�■■■�����■■ ■ ■��■ ■�■■ ■��■ ■��■ ■■�■ ■■■■ ■ ■�■■■ ■���■ ■■■■■ ■���■ ■�■■■ ■�■�■ ■■■�■ ■■■�■ ■■■■■ ■�■�■ ■■■�■ ■���■ ■�■ ■ ■■ ■�����������■ ■�■■�■���■��■ ■■����■■����■ ■■■■■�■■■■��■