109 Old March Rd Lot 9 r
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 989900025 Tax PIN/EH#: 5789-76-5851.09
Billed To: Dick Anderson Constriction Subdivision Info: Marchwoods Sec.1 Lot#9
Reference Name: Dick Anderson Location/Address: Peoples Creek Road 27006
Proposed Facility: Residence Property Size: 3/4 Acre
ATC Number: 2215
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 WASTE CO S' ON IS V ID FOR A PERIOD OF FIVE YEARS.
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Environmental Health Specialist's Signatu -�-- Date:
f rni� -A/? 3 &-GROOM
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�aken as a guar ee that the system will function satisfactorily for any
given period of time. � / nv �
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Septic System Installed By: ""�tiL = 1�
Environmental Health Specialist's Signature Date: ? bt?
DCHD 05/99(Revised)
• , DAME COUNTY HEALTH DEPARTMENT / ?G 0
Environmental Health Section U
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 989900025 Tax PIN/EH#: 5789-76-5851.09
Billed To: Dick Anderson Construction Subdivision Info: Marchwvods Sec.1 Lot#9
Reference Name: Dick Anderson Location/Address: Peoples Creek Road 27006
Proposed Facility: Residence Property Size: 3/4 Acre
ATC Number: 2215
**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 Udllse- #People #Bedrooms —71" #Baths 7—
Dishwasher:
Dishwasher: 2""' Garbage Disposal: Washing Machine:!3 Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size 13D` A27-4C> Type Water SupplyC, ^)Tif Design Wastewater Flow(GPD) —� Site: New Repair❑
System Specifications: Tank Size Cl" GAL. Pump Tank GAL. Trench Width 3(o Rock Depptth� " Linear Ft.--3b6!
Other: j)j STe-1 607k>,� 7?E�jG, JQ-f- t.L Ll "S 14D•Q..
Required Site Modifications/Conditions: rJ 'TA-LJ-, 03 C� TD�� S t 5 e---wo!o
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IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6 K 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.****
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Environmental Health Specialist's Signature: Date: P
DCHD 05/99(Revised)
APPLICATION FOR SITE EVA LUATION/IMPROVEMENT PERMIT ATV
(, Davie County Health Department 0
n � L Environmental Health Section
U P.O. Box 848
Mocksville NC 27028 AN — 8 1998
OCT 2 9r (76)75
ENVIROMIENTAL HEALTH k'
ENVIRON ME 1TIMRORTA T**** THIS APPLICATION CANNOT BE PROCESSED UNLESS DAVIE COUNTY
DAVIE COUNTY ALL THE REQUIRED
7INFORMATION IS PROVIDED.
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1. Name to be Billed ,
D6C& N�C2S D.j C6VS%,_LV C . Contact Person 4A1
Mailing Address yVIN& f f/9(14:-: l/ LAI. Home Phone ' 7S7'7
City/State/Zip 'Movie S t//Cf_'& C �2 70 a Business Phone 33�/�Jq� 7a79
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
/0-29-ff
3. Application For: Site Evaluation Improvement Permit&ATC ❑ Both
4, System to Serve: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms 3_ # Bathrooms
Dishwasher Garbage Disposal X Washing Machine ❑ Basement/Plumbing ❑ Basement/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: County/City ❑ Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes No
If yes,what type?
E I THE R A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PJAIXM THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: R�47- pe'4y 6/Y CLoScp I WRITE DIRECTIONS(from
Mocksville)TO PROPERTY:
Tax Office PIN: # 7 g - - - 5-&' •S% 1
/S8 Tv $a/ - �
Property Address: Road Name � OnC�E�CiPK QO _ 1
1 Ae7- ra /-90 A
City/Zip ADL1,4 c r•E_ Al C a-7oo 6 '
' 7&-,Zv Cmf=r- pn/ /I?u/�ct=
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If in Subdivision provide information,as follows:
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Name: M'4"e CN I
I /YI/CE�•8
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Section: Lot #: I
LC1cX, s OA'
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 T-r,- to conduct all testing procedures
as necessary to determine thesitesuitability.
DATE 6 — (9 ^ 7 & SIGNATURE
Revised DCHD(06-96)
JOU AtrAJ USE THE $ACK OF THIS FORM FOR DRAWINC7 YOUR SITE PLAN.
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504 �/ /� c .'� '' ♦� /��'��' �'/%' /!/ /i%Y�1 / 1 X 71-
,� / _,�' _zgg� _ /,//�/ :''�� / ♦ NOTES
61/ ./ /' �, �__-moi/♦ !/ / ' / ! i��/ 1. ALL LOTS ARE SUBJECT TO DAVIE COUNTY
- `---� /♦_/ ` /' ���� �/ / �ii / // '/ I j /
HEALTH DEPARTMENT STANDARDS
2. ORDS
_
ARE TO BE ,�.L Tn u,� �STAial� _—_