148 Ashley Lane, Lot 6 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 989900573 Tax PIN/EH#: 5831-91-5771.06
Billed To: Glenn Johnson Builders Subdivision Info: Caudle-Angell Rd.Ac.Tracts Lot#6
Reference Name: Glenn Johnson Location/Address: Jetter Lane-27028
Proposed Facility:. Residence Property Size: 5.001 Acres
ATC Number: 2439
**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 11 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 /'T #People_� #Bedrooms S? #Baths_
Dishwasher: Garbage Disposal: PK Washing Machine: 7" Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply Design Wastewater Flow(GPD)`'£ Site: New 2T/Repair❑
System Specifications: Tank Size&-GO�AL. Pump Tank GAL. Trench Width.Q� Rock Depth 'Linear Ft.
Other: C, -)/ A(&
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISERS)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)
t
DAME COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 989900573 Tax PIN/EH#: 5831-91-5771.06
Billed To: Glenn Johnson Builders Subdivision Info: Caudle-Angell Rd.Ac.Tracts Lot#6
Reference Name: Glenn Johnson Location/Address: Jetter Lane-27028
Proposed Facility: Residence Property Size: 5.001 Acres
ATC Number: 2439
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 OF FIVE YEARS.
Environmental Health Specialist's Signature:
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.
3
Septic System In tae y: �,,
Environmental Health Specialist's Signature: '� Date:
DCHD 05/99(Revised)
APPUCATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&
Davie County Health Department
�� ? �O�O
Environmental Health Section
P.O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
***ZNPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Bil-1—qQR-&,64W-W4 AI IO�es -7;c, Contact Person �6-le-74
Mailing Address fJ f�l, 1"Z,.1,, 4 / Home Phone
City/state/ZIP a4.led. Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/state/Zip
3. Application For: ❑ Site Evaluation R-T�p-rovement Permit/ATC ❑ Both
4. system to service: 9-1ro—use ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: --//# People # Bedrooms r� # Bathrooms
�shwasher RIi rbage Disposal C ashing Machine ❑ Basement/Plumbing 0 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)
7. Type of Water supply: ❑ County/City "ell ❑ Community
9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes ello
If yes,what type?
***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
01 Property Dimensions: " �nf._ fo 'aa,�e sd�,56,66 Ja$11ITE DIRECTIONS(from Mocksville)to PROPERTY:
Tax Office PIN: #5V/7S�s-5-7-7-/Ld5
Property Address: Road Name 3-o T' eJk- ka-4 e Pb+I1):Ahe Sc k oo I e4 on Pc. k g k,Li. P
City/Zip {Y \dG°5 Up' OA (�g nn " 40 e,( 1W
If in a Subdivision provide information,as follows: F Q-4 0--,
Name: l a�be Yet 1`� kJ�C-+S
Section: Block: Lot: _ Date Property Flagged:
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,4 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 Depar ment
to enter upon above described property located in Davie County and owned by /t egll r R
to conduct all testing procedures as necessary to determine the site suitability.
DATE ,`�-l7�d SIGNATURE � '1
THIS AREA MAYBE USED FOR DRAWING YOUR SITE PLAN(Incl all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
,. �Account No.
Revised DCHD(07/99) Invoice No. 1r4!5)15
Tax a ' '
•„ `fly 1t;r^Y�' .,•
=WS chard
Walker
u 89 40.05"E
•• ; Parcel 41,',�• I \ $ ro
t.•tw• . , ' I N
2
N 89.49'10"E
•x. 258.15
7 e " �O '
638.0827 1
p 11. 41,
lent
5 ,
CN
066 Acres
5 . 000 Acres Z '
it . • ;.t�,•il. � � g/ •_~ 525.70' Total i
1181.00,E 8. O'• rn tI
To be conveyed '
to �_ N 89.49.10"EW 30,00•
a I Hal Thomon McCulloh, Jr.
a
r. '� •+• •:1� , k
.A.,•.-vf •
Jv
5.001 Acres. ,; '001 AcresL Y
ai<v
Jri�• I i S 88.59.10"E ~
30106' • 536.28 Total k
To be conveyed to 478.35' 3002
5:739 'Acres 5 . 001 Acresjr '
M�zi• 518 66 a.
f' N 88.59'10 W,54866'-Total :?
NIP
l I tL210.52
1 S B1�B•Op"W w
n. . i.
hiv
11 tv
�.1 Ijl }'• WL MOM � • 1
5.281 Acre
sN a
T — — 586 74•
Angell Rd. S.R. 140 , - - N 88.5
C
WfUr
Parcel 3
E TSt
v . f '•r .t '::
Jkmijo
. . �;..�.a�•'