102 Creekview Dr Lot 33 • �� DAME COUNTY HEALTH DEPARTMENT
Environmental-Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 989900241 Tax PIN/EH#: 5880-51-2809
Billed To: Craig Carter Builders, Inc. Subdivision Info: Magnolia Acres Section II Lot#33
Reference Name: Marty Coeler Location/Address: Peoples Creek Rd.-27006
Proposed Facility: Resudence PMPP[jy,';i7t-_-
ATC Number: 4303
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 11 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: Date:
Date:
CERTIFICATE OF COMPLETION
Dov
**NOTE** The issuance of this C tate of Completion shall indicate the system descri d on Improvement/Operation Permit
has been installed in ance with Article 11 of G.S.Chapter 130A, 1 .1900"Sewage Treatment and
Disposal Systems,"but shall in I�(�/ em will function satisfactorily for any
given period of time. !t
46 /
F
Septic System Installed By:
Environmental.Health Specialist's Signature: 116p � Date: S
DCHD 05/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account M 989900241 Tax PIN/EH#: 5880-51-2809
Billed To: Craig Carter Builders, Inc. Subdivision Info: Magnolia Acres Section II Lot#33
Reference Name: Marty Coeler Location/Address: Peoples Creek Rd.-27006
Proposed Facility: Residence Property Size:
**NOTES*"Thislmproveme3nt/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 #People _ #Bedrooms z #Baths,�—�
Dishwasher: Garbage Disposal: Washing Machine Basement w/Plumbing:;23` Basement/No Plumbing: ❑
Commercial.Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply Design Wastewater Flow(GPD) Site: New e Repair❑
System Specifications: Tank Size/dbGGAL. Pump Tank GAL. Trench WidthQ-r4110
Rock Depth Linear Ft.
i
Other: As stated in 15A N AC 18A.1969(5)
accepted Systems may also De u5co
Required Site Modifications/Conditions:
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)
f FOR SITE EVALUATION 11111 1tOVEh1FM PERMIT&ATC
� ° '� Davie County Health Department
{
ITC,1 Environmental Health Section
i .O. Box 848/210 Hospital Street
` JAN 1 C 2006 Mocksville, NC 27028
(336)751-8760
R.
* *IilPORTAl ,!,* pU,,WIS APPLIC TION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFOR21ATION IS PRO' D eFor to the INFORMATION BULLETIN for instructions. f
1. Name to be billed V/G? ! nj Contact Person
Mailing Address home Phone
City/State/ZIP ,1��✓�✓�Cr A/l cs717b G Business Phone ��-s'-3 7
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For:. ❑ Site Evaluation ❑Improvement Permit/ATC Vr Doth
4. System to Service: 7kHoune ❑ Mobile Home ❑ Business ❑ Industry ❑ Other_
S. Type system requested:�Conventional ❑ conventional modified j ❑ innovative t3accepted
6. If Residence: it People # Bedrooms 7' it Bathrooms �.•J�'
shwasher rbags Disposal i Clidashing Machine cement/Plumbing ❑Basement/No Plumbing
7. If Duainess/Industry /Other: verify type # People # Sinks
9 Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: It Seats Estimated Water Usage (gallons per day)
S. Type of water supply: ❑ County/City ❑ Well ❑ Community
9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes ❑No
If yes, what type?
***L111'0Rt-1NT***CLILNTSAIUSTCOAIPLETETHE REQUIRED PROPERTY INFORiV1AT)ON REQUESTED
BELOIV. Either a PLAT or SITE PLAN AfUST BESUUBAHTTTE•D by the client with THIS APPLICATION.
Property Dimensions: e, /�f?lcHL �" A"'•-WRITE DIRECTIONS(from iVlocksville)to PROPERTY;'
Tax Office PIN: # 5-9y0'15-1' 7-1?09
Property Address: Road Namc
phred 0
Oq /0U 90033 City/zip
If in a Subdivision provide information,as follows:
Natne: :ln e/c Ae ref
Section: - Bloch. Lot: Date home corners 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,or if the information
submitted in this application is falsified or changed. I,also,understand that I ant responsible for allc rges ' Fred fr in
this application. I,hereby,give consent to the Authorized Representative of the Davie Count ald ar
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine the site suitabilit
DATE A/4�1—O.'S-- SIGNATURE
TIIIS AREA rJAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the follow;n : Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Date(s):
Client Notification Date:
EMS:
Sign given Account No.
Revised DCUD (05/03 Ittvoice No.
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CREEW� NE GRAPHIC SCALE —
FEET
AIA°����'���\ FOR CRAIG CARTER BUILDER INC.
SCALE TOWNSHIP COUNTY STATE DATE,s
TULIP MAGNOLIA DR g o
w SITE PLAN O NLY , 1" = 30' SHADY GROVE DAVIE N. C. 1-17-06
la THIS WAS MAPPED FROM A DEED OR LOT 33 MAGNOLIA ACRES PHASE 2 P.B. 8 PG.75
In RECORD PLAT AND NOT FROM A SURVEY
PEOPLES CREEK RD BY M
HOWARD SURVEYING JOB N0.
LOCATION MAP JOHN RICHARD HOWARD PLS 06009
P.O. BOX 276 ADVANCE, N.C. (336) 998-5396