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326 Georgia Rd1 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900063 Tax PIN/EH #: 5811-00-3463 Billed To: Larry McDaniel Subdivision Info: Reference Name: Location/Address: 326 Georgia Road -27028 Proposed Facility: Residence Property Size: see map ATC Number: 3460 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction 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 1 l of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People _j #Bedrooms_ #Baths d Dishwasher:.,J� Garbage Disposal: ❑ Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #Pe,,��op//le #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply. ��'Dessign Wastewater Flow (GPD) _,01 G' Site: New Repair ❑ System Specifications: Tank Size/ ja GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width s Rock Depth /Linear F/ IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) • • • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900063 Tax PIN/EH #: 5811-00-3463 Billed To: Larry McDaniel Subdivision Info: Reference Name: Location/Address: 326 Georgia Road -27028 Proposed Facility: Residence Property Size: see map ATC Number: 3460 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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD �OFF FIVE YEARS. Environmental Health Specialist's Signature: h Date: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit 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. UP] IF Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Ll Date: AI -1 2 -6� • . r,'r']APP.LICATION FO SITE EVALUATION/IMPROVEMENT PERMIT & ATC r_ „' avie County Health Department ` F 'En vironinentaiHealth Section o P1. Q. Box 848/210 Hospital Street G NO3 1 ' Mocksville, NC 27028 u11(336)751-8760 ** ROAN * 7.IJSP L�' A..,W ION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IRWI er to the INFORMATION BULLETIN for instructions. - Name to be Billed rnC .1 )On e)U; ((JUS-2entact Person MC ►C c- r►- �_Mailing Address O � Home Phone t� `_City/State/ZIP mor C I �. � c— c � �rusiness Phone /��- 0 �S Name on Permit/ATC if Different than Above Mailing Address Cityjute/Zip _ �. Application For: Site Evaluation Impro ement Permit/ATC Both System to Service: House ,Mobile Home Business Industry Other Residence: # People I # Bedrooms # Bathrooms _ Dishwasher Garbage Disposal Washing Machine Basement/Plumbing Basement/No Plumbing -------------- 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) Type of water supply: County/City CWell Community `-T' Do you anticipate additions or expansions of the facility this system is intended to serve? Yes No eyes, what type? ***IMPORTA ** CLIENTS MUST COA PLETE THE REQUIRED PROPERTY INFORMATION REQUES'T'ED BELOW. Either a PLAT or SITE PLADLVUSTBESURAfITTED by the client with THIS APPLICATION. `fPronerty Dimensions: W ; DIRECTIONS (from Mocksville)'tooPPROPERTY: 'Tai Office PIN: # 5 1 �� Q H W u• U 0 l �� 1 perty Address: Road Name3a W L52A(Q, 0. 4� ocU ba -4L CJ--.,, ILUt City/Zip Mocx.0 U i 1(J n C _ If �.n a Subdivision provide information, as follows: 1` AMC: ection: Block: Lot: onie corners flagged: 51 a 1p� 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 thi application is falsified or changed. I, also, understand that I run responsible for all charges incurred fi•ou: this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon a Bove described property located in Davie County and owned by to conduct all resting procedures as necessary to determine the site suitability. ) L,'/DATE �l �lO LA<GNATURE�G - M L.� a,,� _1,��!-). L THIS AREA LNIAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). r� fit... Sign given_ 0 Revised DCI::D (07/99)OG� - e -O -Lt '-s Site Revisit Charge Date(s): Client Notification Date: EHS: Account No, fl O 63 Ittvoice No. 3--574 Fir L-� Tax Lot 23.12 Tax MOP F-2 n f Joseph Anthony Golding lB 385 p PG 363 S 86032'45"E 861.96' Total Part of Tax Lot 23.12 5.601 Acres +/— (Inclusive of area within SR 1313 R/W) 1114.56' Total N 86.32'45'W 1061.31' IRS In Branch 430.98' — r L-5 PrL-6 L-7 Proposed House as Flaggedr-"-.. — _.� P I P io P Branch Branch 258.73' N 86.32'45"W Lr ■■ no ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■E■■ME■E■■ ■ME■EN■■■ no ■ ■ ■■■M■ MENS■ SEEMS ■ ■ SOON ■N■■ OMEN ■■M■ NONE NONE NONE ■E■■ ■O■■ ■O■■ OMEN SEEM ■EE■ No MEMO MOON MEMO 0