The URL can be used to link to this page

848 Fork Bixby RdHEALTH DEPARTMENT RELEASE Davie County Health Department --- Environmental Health Section 210 Hospital Street Mocksville, NC 27028 Phone:336-753-6780 Fax:336-753-1680 Permit Valid Until: 04/22/2019 (Applicant: James White ` pp Property Owner: James White Address 848 Fork Bixby Road Address: 848 Fork Bixby Road City: vaur-e-_ City: Advance State/Zip: NC / 27006 State/Zip: NC / 27006 Phone #: Phone #: Property Location S Site Information Address: 848 Fork Bixby Road Subdivision: Phase: Lot: Road#: Advance NC 27006 Township: *Structure: SINGLE FAMILY # of Bedrooms: 2 # of People: Directions:Hwy 64 E. right on Fork Bixby Rd. on right just past Livengood road. *Water Supply: PUBLIC Type of business: Basement: ❑ Yes FX No Total sq. Footage: No. Of Employees: *Proposed Improvement: Expand Bedroom *Release Conditions: **Site Plan/Drawing attached.** Total Time: (HH:MM) OHand Drawing OImport Drawing Hours Minutes Activity Code: HEALTH DEPARTMENT RELEASE i, Davie County Health Department *1� Environmental Health Section 210 Hospital Street Mocksville, NC 27028 Phone:336-753-6780 Fax:336-753-1680 Permit Valid Until: 04/22/2019 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? Applicant/Legal Reps. Signature: *Issued By: Nations, Robert Authorized State Agent: ��i ❑ Yes ❑ No *Date: *Date of Issue: 04/22/2014 **Site Plan/Drawing attached.** Total Time: (HH:MM) OHand Drawing OImport Drawing Hours Minutes Activity Code: W h4e r, w(d like 4o ,be . &/tg- Davie County Health Department 4 his I�, Environmental Health Section P. P.O. Box 848 Date: -i�`� 210 Hospital Street J;D 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: �A a e 5 . L r Phone Number �33 y Xy L a (Home) Mailing Address:`{ q '? --� 0 7-[.< IF L, q g (Work) H d (.JAL. 0C. p Email Address: Detailed Directions To Site: Property Address: ; i 7 - 000 00 • kZ Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: L' G� t�(7Cl iE�� Type Of Facility: Date System Installed (Month/Date/Year): /`'/ U G Number Of Bedrooms: x Number Of People: o_ Is The Facility Currently Vacant? Yes No If Yes, For How Long? Any Known Problems? Yes 0 If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility:EY/�� !��0 /Y1 Number Of Bedrooms: Number of People. Pool Size:_ ii I Requested By: Size: Other: Requested: If For Environmental Health Office Use Only Approved Disapproved Comments: 1/1 « l't°� \' /ter' X! ' "S G i7 /I/ l/e"/ Environmental Health Specialist. *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. PaymenCash Ch,ecj MoneyO der # Amount:$ Date: &.l%l - Paid By: -7J�� '�� Received By: Account #: 13 75-7 Invoice #: ml . 5 L� r Termit -t- s 1 Name: r �J Directions to property: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O. Box 848 AUTHORIZATION NO: 0 0 2 9 833 A ��1� i#o PROPERTY INFORMATION Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 Section: AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Tax Office PIN:# C. / ,J G, , Jr y • t . Road Name: Lot: .1 Al Cf� Zip: **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental 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 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ( � e' -"17 ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION 09 F ,, c' ( vI IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED 'j 7 RESIDENTIAL SPECIFICATION: BUILDING TYPE / # BEDROOMS -3 # BATHS -2 # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No r --r LOT SIZE TYPE WATER SUPPLY cd DESIGN WASTEWATER FLOW (GPD) 3 NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE '� GAL./PUMP TANK -"GAL. TRENCH WIDTH l ROCK DEPTH NW-LINNEAR/Fr. 3/�7�1 OTHER cccd pied Systems, may b;: LIS --(l REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT �- r � L ,K 4` 11 FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 1 OPERATION PERMIT SYSTEM INSTALLED BY: C V d AUTHORIZATION NO. �" OPERATION PERMIT BY: DATE: �- **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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 02/02 (Revised) Al f, +PermitO s v%:T j DAVIE COUNTY HEALTH DEPARTMENT Name t Environmental Health Section PROPERTY INFORMATION P.O. Box 848 Directions to property: Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 -� Section: AUTHORIZATION FOR WASTEWATER Lot: SYSTEM CONSTRUCTION Tax Office`PIN:# - - AUTHORIZATION NO: 0 Q 2,11-3 Pj A Road Name j Zip: **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental 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 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. VI O TAI- HEAL H ATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS --3—# 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 SIZE ` Y GAL. PUMP TANK GAL. TRENCH WIDTH ' rf ROCK DEPTH % yr!rJ LINEAR/FT. 3� 7O OTHER �G''G1 Gt C c yl REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT �— � / r V 4 I FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. r OPERATION PERMIT SYSTEM INSTALLED BY: I-, I/ V �- 4 �141� ►� 311 AUTHORIZATION NO. OPERATION PERMIT BY: ''f'%f/s� DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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 02/02 (Revised) 0 DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) PHONE NUMBER ADDRESS filizk- v . A " Il e.) SUBDIVISION NAME LOT # DIRECTIONS TO SITE lD� G �'�f d11� ��'�: � / r ho, d,,J AW DATE SYSTEM INSTALLED F( NAME SYSTEM INSTALLED UNDER TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING 14 DATE REQUESTED Z'I / INFORMATION TAKEN BY 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. 1/93 GoMAES - D.;.vie County NC Public Access Davie County, NC - GIS/Mapping System ".i43 n3> jC"4; �., Click Here To Start Over v' �, =� '• t`,ctiue. Layer. Ofist: !'faa Ti;--) ® PARCELS (Map Tips Available) i � � r 1 L 0 568 Page 1 of 1 Quick t. iearrlr:(County ID or Ouiner Ni s ri "'ENGOOD RD - :t, I j-- --I _ 1 -T —, http://maps. co. davie.nc.us/GoMaps/map/Index. cfm?mainmapservice=gomaps&CFID=41... 10/22/2009