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455 Comanche Dr AUTHORIZATION NO: DAVIE COUNTY HEALTH DEPARTMENT • �` V Environmental Health Section PROPERTY INFORMATION Permitte s ' P.O.Box 848 ...-�,,. Name: " Mocksville,NC 27028. Subdivision Name:. r'�, j r Phone#:704-634-8760 nsfProperty: Section: r Lot: . AUTHORIZATION FOR WASTEWATER Tax Office PIN:#�� - SYSTEM CONSTRUCTION Road Name: Zip ff (!J **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 l l of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) /i,I '^ ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION i � i[l F� v '' IS VALID FOR A PERIOD OF FIVE YEARS. NVIRONMENTAL HEALTff SPECIALIST. DATE ISSUED, rr Act ..�:��.a d. awl O .. 1 4 5 DAVIE COUNTY HEALTH DEPARTMENT 77V }-" o IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Subdivision Name:-, Directions to property:- �r, ;.ri ^fes' Section: �►`� Lot: r IMPROVEMENT - PERMIT Tax Office PIN:# e: Road Name: r'/xlfi)'iyu-&- Zip: **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 CONSTRUC 40N 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 _ ".�� ; ((-;!� ,;, r to ; a/;�` �f} '`✓ PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER tNVIRONMENTAL HEAL11 APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERN -8z A / Davie County Health Department 0 W LJ Environmental Health Section Ci P.O. Box 848 AUG'2 2 1997 lY Mocksville,NC 27028 (704) 634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billedy Contact Person N Mailing Address 0,4 a Home Phone " ") — City/State/Zip C Q•M r�N S N C a 0\a Business Phone `)0!A - !Ass — $y51 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: Owe Evaluation [q*Improvement Permit&ATC [ ]Both 4. System to Serve: [ Wouse [ ]Mobile Home [ ]Business [ ]Industry [ ]Other 5. If Residence: #People #Bedrooms— _ #Bathrooms a [-I-Dishwasher[ ]Garbage Disposal [Washing Machine [ ]Basement/Plumbing [-rBasement/No Plumbing 6. If Business/Other:Specify type #People #Sinks #Commodes #Showers #Urinals #Water Coolers If Foodservice:#Seats Estimated Water Usage(gallons per day) 7. Type of water supply:l"It ounty/City [ ]Well [ ]Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes [eKNo If yes,what type? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED:***IMPORTANT**#"M OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: n�� X �`\� X P-'\O X WRITE DIRECTIONS(from Mocksville)TO PROPERTY: Tax Office PIN: # _- Property Address: Road ame C o nhn n&e tW t,v I c �N o a C p b TO 41 XPJ— O I', 3 4L City/zip �a�.,e►.0 1 0 !'„ ; iJ!Ze If in Subdivision provide information,as follows: Name: 7C n o ti \N'k\\S- Section: Lot#• \`( 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 and owned by u to conduct all testing procedures as necessary to determine the site suitability. DATE g•�S'�1 SIGNATURE -- Revised DCHD(06-96) THIS AREA 11(AJ $E 11SEb FOR DRAWINC 1/011R SITE PLAN: f� 0 U-:5-e, cA6 do, C - r , bb cd;,y;,,.T'r"��'XY Ytw °`',,`"r.� t;�'�.;xr.r:r ,a -��«t.a , f el. 3`ir r •x, r � t _ _ S'{ h ,Y�'+ .r i _ ,t;. Fyeamu; ,AUTxoRIZATION NO: Q 9 3 5 'DAVIE COOTY HEALTH DEPARTMENT t ` k. Environmental Health Section PROPERTY INFQ$MATdON #/74 Pomitt'ee°s -P.O.Box 848 -:'� wd/0111 Name: .. l1111 �C i9�j� Mocksville,NC 27028 Subdivision Name: "` `' �°% r Phone#:704-634-8760 Directions to property:-/ 7/17✓�a<' Section: Lot: AUTHORIZATION FOR �� d ' WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION - PPD: Road Name: D C� 1 ZC o a( **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) ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALn SPECIALIST DATE ISSUED � - � C\ APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section • R 0. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 1. Permit Reque By �D L;' r Business Phone 2. Address e 3. Property Owner if Different than Above Address 4. Permit To: a) Install �Alter Repair b) Privy Conventional ther Type GroundAbsorption c) Sub-Division7OVA Al 14 'I(C Sec. � Lot No "f 5. System used to serve what type facility: House mobile Home Business II Industry Other b) Number of people `� 6. a) If house or mobile home, state size of home and numb r of rooms. House Dimensions coo �-� / Bed Rooms Bath Rooms Den w%Closet b) If Business, Industry or Other, State: Number of persons served What type business, etc. Estimate amount of waste daily (24 hours) 7. Number and type of water-using fixtures: commodes —3 urinals garbage disposal lavatory showers a" washing machine dishwasher inks 8. a) Type water supply: Public Private Community b) Has the water supply system been approved? YesNo _ 9. a) Property Dimensions 2qQX= b) Land area designated to building site �✓h e-� e— �v 2r d pS��Lc, ��a.. P - c) Sewage Disposal Contractor 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? What type? This is to certify that the information is correct e b nowledge. Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: kv ,w X 14 v� v S �o 2) `l DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. 0. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name Date /�2 Address Lot Size FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S PS PS U U 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) PS PS PS U U 3) Soil Structure (12-36 in.) S S S Clayey Soils PS PS PS PS U U 4) Soil Depth (inches) S S S PS PS PS U U 5) Soil Drainage: Internal S S S S P- fp PS PS U U External S S S PSPS PS Kb�' (!�> U U 6) Restrictive Horizons f �J_ iM"r-r 7) Available Space 69 n S S PS PS PS PS U U U U 8) Other (Specify) S S S S PS PS PS PS U UU U 9) Site Classification El• /)-,)5—, U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: Described by Title Date SITE DIAGRAM �a >raareq DCHD(5.82) Pailie QlauntV1 Xealt4 PEpMxtment M2t� �IItttP �EMI�Ii ��EICt�1 P. O. BOX 665 f acksWile, North Qlaralintt 27028 OFFICE OF THE DIRECTOR TELEPHONE December 23, 1986 (7041 634-5985 Potts Realty P.O. Box 11 Advance, NC 27006 Mr. Potts: On December 19, 1986 this office evaluated two lots in Indian Hills. Lot 17 is provisionally suitable on the extreme back side. Lot 18 is classified provisionally suitable. Before any permits are issued the appropriate application must be filled out and each house location staked off. If you have any questions, feel free to call. Sincerely, Robert B. Hall, Jr. R. S. Environmental Health RBHJR:sg Jure-17-97 05:01A Hubbard Realty Davie 910-998-4492 P.02 i APPLICATION FOR SITE EVALUATIONIEWPROVEMENT PERMIT&ATC Davie County Health Department Environmental Health Section g P.O. Box 848 Mocksville, NC 27028 (704)634-8760 ****INH)ORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIRE 1. Name to be Billed �� d G Q�L Contact Person v4.441 /"ee4-16( Mailing Address t hI Home Phone r ��"�-A614V-d'9741 > -�7L/ City/State/Zip J�.()rA/,rVOd• Irk , ��- 7-71,o4Business Phone I'd -.Z731 2. Name an PermitlATC if Different than Above Mailing Address City/Statemp 3. Application For. [ 1 Site Evaluation 1/1 Improvement Permit&ATC ( ]Both 4. System to Serve: [t,rouse ( ]Mobile Home [ ]Business [ ]Industry [ Zishwasher r 5. If%=shing ce: #People Z #Bedrooms 3 #Bathrooms Z [ ]Garbage Disposal [ Machine [ ]Basement/Plumbing [ ]Bascment/No Plumbing 6. If Business/Other:Specify type #People #Sinks #Commodes #Showers #Urinals__---L #Water Coolers If Foodservice:#Seats Estimated Water Usage(gallons per day) 7. Typc of water supply: [ County/City [ ]Well [ ]Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes MNo If yes,what type? EITHER A PLAI Olt SITE PLAN PROPERTY INFORMATION REQUIRED:***IMPORTANT**.SIC]=T OF THE PROPERTY MUST BE SUBMITTED WITHM S APPLICATION. Property Dimensions: I��YJ "/`f�G 1� Q�� C-S�`/ WRITE DIRECTIONS(f ckaville)TO PROPERTY: Tax Office PIN: # - - Z--As% &1,6J a Property Address: Road Name — da .,Q, City/Zip dQ . /1G R •;e ,z e/p/ If in Subdivision provide information,as follows: it/,/D el' Name: — tld;AJ kkS M,1.ts AfMS Section: Lot#: 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. 1, hereby, give consent to the Authorized Represen ative of the D County Health D artment to enter upon above described property located in Davie County and ewees} l�:t/ca/ by AZIPAt to conduct 1 res' pr/ocedures as necessary to determine the site suitability. DATE /`� 7 SIGNATU AlG �p , Revised DCHD(06-96) i A l R£ Pl1/}�/ THIS AREA ,Wilj BE USED FoR DRAWINC 1101IR SITE /T-AN: ��1d�Q/rn��/`�"�9�d�9�� '�2o cv Ir vdve-CL •M,JUn-17=97 05:02A Hubbard. Realty Davie 910-998-4492 P.03 46 • �. r ,. �: AAf,�, s. x� Arext� `` {� +;J:14�Nstas• �R/�:'�:f�7 Aa�tt=: .Atfw� S. •t •• .� .a.' .�:. '.�'. �I, '• a ti• f7j'.tCtt'Ii. A '�Y• :r •,./,;-; .. � t� � {C.• r Vii:� �'�'� 0 ,'Y�.. / !► ..• ' •� . .! •fir: /: tit}'/`I t. :i.: j� : R'�, ti ,i•''V,••v�.. ` Y•.•', .r';i'G,.. *. �.r .rt.Fi ,. • : lb t �1 .' .r ' n =,r. .. .Y STK , .. • .,• ;-�•',�� r ;+•.5:,�'~ •��• .i.�' .. :�:. irk .. . .L+,, • do •iXi';• ' :: t ;� rrl• � ten''•:'( �:r��.r• •�;.�~�•,•.. .t ~ •�.' .,:{y ;y; • iXisL��s �3 �� .' '•t•"'•a't..�%,)•'t+.+��.." '" � [�r!' '.•;. .. _ - �'•;•;;;:: ;1�:±'rtY.�,. :. i:::. ��_ t"^',, �•. Y• i :T'.-• i• rift • •_�' I. "'Y,��:• �'.:i' s•+, r' ' Os:b3"'.sv'. a �««w}srx D!••It N,,t tt 4/irA.' /G6.a ehh44./� ' IT •s/ ��7.Vt6' 7.10 t 17T.d _ v.''y�-,�,t� � • ':"Y�:2`S• ;."�` Orsi. Ct.Rvi �Ai.1 �• 4.j Ir �_= `�`` � '�.. � �.,:: .fes �->�44- .,• t* .�.. ..• ,� y• - _ ,� ..'t�%�_yrs' T ' i��..0 .. '� •,�� ',r:y' Ifs) - '"i' "�' �� _$; �•411 ".•.'•'•.`�-� /a /♦ P 47 it A!#!'_ S.f+s •iltlhtt _ r !St!'!M•� ;s: /f 3F� :/i1 JF!.�t '�l�lr/+�' a./C�,}rtRs.. �•J�l'i.f�.'S:IOt Aot w Tf:_ •: 'ae=_!Imp .� •t p .• IF !-" serif h poll tA �rrc:y:, ',, ,►`r•:.!1:yip'• 't A;'ko. , •U �.. �: '..,y.I�l::...c' - um :i'_3vr a.f/•J_t� --__; '•9•.�>�•�.lt� �..'�'•.. _ •,:�___r•�+�.M.a� .� ,_ �•_��,��'.O ��'d.r,I�� _ r:'��• �.x; .�,.I.::;u:` :.' .r.f,jwy+' '� r ,J•• r �� .•% t C.':.;:4';'I.,+,..., , ,• T%/'•"-'S; 7'M i.h, iIr•,••....• •r'-'"'•yrf„ 'y' •' ,'T..�.�'y , .57 "A .i.%`iS,'.�,.!/.✓•rS,�R:y��,'' •�"�,1�`;fr.�',�f;�ii. •.t+r:'�' 'r •,:• ri(::+�. ..�� p' •j �i ,� ,S '!' 4' it�, '"1•.1':�' STATEMENT DOM COUNTY HEALTH DEPARTNWM ENVIRONMENTAL HEALTH SECTION 210 HOSPITAL STREET P.O.BOX 848 MOCKSVILLE,NORTH CAROLINA 27028 (704)634-8760 Payment Due Upon Receipt of this Bill. Detach and Mail a Copy of Bill with your Check. Your cancelled check is your receipt. Julys, 1997 Jaun Becknell 333 Jonestaatn Rd. , Suite 105 Winston—Salem, - NC 27104 07-03—S7—!Permit/ATC ##093 Indian Hills I/Lot 17 SEP - -3 NOW �� PPLAF!CE DUE SOW — ` $Y.t'_O STATEMENT . 'IDA VIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION 210 HOSPITAL STREET P.O.BOX 848 MOCKSVILLE,NORTH CAROLINA 27028 (704)634-8760 Payment Due Upon Receipt of this Bill. Detach and Mail a Copy of Bill with your Check. Your cancelled check is your receipt. August 8, 1997 SECOND NOTICE Jaun Secknell 353 Jonestovn Rd., Suite 105 Winston-Saler, HC 27104 ,4 07-03-97 PermitlATC 00935 �a0.00 Indian Hills I/Lot 17 o !:! DALARCE DUE HDti - $50.00. ;v r STATEMENT -DA WE COUNTY HEALTH DEPART WM ENVIRONMENTAL HEALTH SECTION 210 HOSPITAL STREET P.O.BOX 848 MOCKSVILLE,NORTH CAROLINA 27028 (704)634-8760 Payment Due Upon Receipt of this Bill. Detach and Mail a Copy of Bill with your Check. Your cancelled check is your receipt. November 25, 1 97 Jeremy Oxendine 157 Ashton Court Clenmons, NC 27012 11-25-97� Permit/ATC 101145 (Indian Hills I/Lo1 17)_� *50.(N 1 i 3I-__--- - �M AAL aNCE Uig. NOW - � $501.00