158 Hidden Passage Way` ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
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IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST •' DATE ISSUED
'y 1451'DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
rd
Namettee�lI ,�Q ��1■,�D� Q� Subdivision Name: _9�" r.E7P� F•fP�,,
Directions to property: Section: Lot: �"� I sem"
IMPROVEMENT
S
--- 'PERMIT Tax Office PIN:# �.� 1_
E:
rO`Zip:
Roadr
**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
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)
. ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
/ ria > =;°�!r i'"' `• PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
d _
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS .2— # OCCUPANTS GARBAGE DISPOSAL:D or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No
T40
LOT SIZE TYPE WATER SUPPLY �G7 DESIGN WASTEWATER FLOW (GPD) '^� 40 NEW SITE r REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZV L' l "GAL..PUMP TANK GAL. TRENCH WIDTH .14'�' ROCK DEPTH LINEAR Fr."
OTHER
:REQUIRED SITE MODIFICATIONS/GOND
ITIONS:
I'
' **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT `
SYSTEM INSTALLED BY: F
<1" o�
I. 6WI
AUTHORIZATION NO. �J7 OPERATION PERMIT BY: LA%�''/ 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 05/96 (Revised)
t-
' APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT C� U
Davie County Health Department
Environmental Health Section
P O. Box 848 JUN — 9 1998
Mocksville NC 27028
( {5 p "ppall
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED U L
AL jL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed vv!/� //`� 1 /�/ O $ % Contact Person
Mailing Address/%3 i✓E{'f� �!A/rls/�/y/� �L�l� Home Phone
City/State/Zip ��C.rySY/��P /V. . (.�. 02�® � Business Phone /Y P/ler,--�
2. Name on Permit/ATC if Different than Above �%�� /�L5 ® VIE--
-
IEJ- City/State/Zip
M, Improvement Permit & ATC
Mailing Address
3. Application For:
4. System to Serve:
5. If Residence:
C� Dishwasher
❑ Site Evalua��ile
tion
❑ House Home
#People
9" Garbage Disposal
6. If Business/Other: Specify type
# Commodes
If Foodservice:
7. Type of water supply:
# Showers
❑ Business ❑ Industry ❑ Other
❑ Both
YOU MAY USE THE BACK OF THIS )=01tM FOR
# Bedrooms _� # Bathrooms �—
Cg Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
# Seats
®' County/City
# People # Sinks
# Urinals
Estimated Water Usage (gallons per day)
❑ Well
# Water Coolers
8. Do you anticipate additions or expansions of the facility this system is intended to serve?
If yes, what type?
❑ Community
❑ Yes C9" No
k] L tit It A PLAT UR 5 L TL PLAIN
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PRATOR'THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: �:J `�' (y ! I WRITE DIRECTIONS (from
1 Mocksville) TO PROPERTY:
Tax Office PIN: #
15?0
Property Address: Road Name �W �-O X &4Z 9/y�
I n® a 1���,-�
City/Zip 4, LY/ � r i
If in Subdivision provide information, as follows: I O E
Name: LJAI_r MW& LO) 1
1
Section: Lot #:
1
1
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter
are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is
falsified or changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to
the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County
.A _ / ) � n.
and owned by t!lflkK
as necessary to determine the site suitability.
DATE SIGNATURE
Revised DCHD (06-96)
conduct all testing procedures
bIZ,4WZNG y0U1Z SITE PLAN.
.
w
i
y1� k
LAKE 13
MAM HUr
y
vir.o
,m
6.0611 ACRES+—o��i , ;vo►
�
N
3 S 85.50
s 6.0067 ACRES+—
—► TOTAL
N• S 66•s1'27"E 1175.76• 96
� ,_436` Mr
6.6611 ACRES+—
bD
W E
S
up
N 05.27.53"U. 1 ----N
. 162.46'
PRIVATE EASEMENT ;- "r 50,W
N 89•�27"W-
i w
i
N 8121'27-W 1148.1!!'RAYL4M J. CLINTON C. CORNATZER
D.B.174 PG.261 MARKuwD f �� = / ��
D.B. 86 PG. 548 —
� N
1 ��
�n
13
Ooti�
EE
S 89.51'27"E
50_00'
\
Nr Q�
�'
FOX RUN
P.B. 5 PG. 182
N 05.27.53"U. 1 ----N
. 162.46'
PRIVATE EASEMENT ;- "r 50,W
N 89•�27"W-
i w
i
N 8121'27-W 1148.1!!'RAYL4M J. CLINTON C. CORNATZER
D.B.174 PG.261 MARKuwD f �� = / ��
D.B. 86 PG. 548 —
100
Ooti�
EE
� \e4�1V D�**"�`RSP
\
�
MAP
rAH ROD FOUND
FOX RUN
1 4' P.B. 5 PG. 182
1"
DAL
\� N 68.40'25"W 80.00'
Davie County Health Department
and.Come Health Agency
SFE
N�Jpv �`� � 8 g0 %js z5 - Environmenta(Health Section
P.O. Box 848 / 210 HosairAL STREET
COURIER #09-40-06
MomsvtLLE, N.C. 27028
PHONE: (704) 634-8760
May 14, 1998
Mark Edward Roy
173 New Hampshire Ct.
Mocksville, NC 27028
Re: 2 Site Evaluations
Half Moon Lake/Lot 4
Tax PIH: #5851-64-3332
Dear Client(s):
As requested, a representative from this office visited the aforementioned
sites on May 13, 1998. Based upon the information provided on the
application(s) for site evaluation(s) and after the evaluations were completed,
site 1 was found to be provisionally suitable for the installation of an on-
site sewage disposal system, and site 2 was found to be provisionally suitable
for the installation of a modified, oversized on-site sewage disposal system.
SPECIAL NOTE: *Before any permit can be issued on any specific lot in the
abovementioned subdivision, a map (one that will be or has been recorded with
the Register of Deeds) must be provided to this office.*
Before any permit(s) can be issued the appropriate application(s) must be
filled out and the house/mobile home location(s) staked off.
If you have any questions, please feel free to contact this office.
Sincerely,
AX11-
Robert B. Hall, Jr., R.S.
Environmental Health Specialist
RH/wd
Enclosure(s)
cc: Zoning Office