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117 Old March Rd Lot 10 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900025 Tax PIN/EH M 5789-76-5851.10 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Sec.1 Lot#10 Reference Name: Dick Anderson Location/Address: Peoples Creek Road 27006 Proposed Facility: Residence Property Size: 3/4 Acre ATC Number: 2216 **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 H ouS` #People #Bedrooms #Baths Dishwasher: G3"-' Garbage Disposal: D'*--Washing Machine: © �—Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 125 �` `g' Type Water Supply(2t7OtJT-`rbesign Wastewater Flow(GPD)3wc-> Site: New Repair❑ System Specifications: Tank Size IooCbAL. Pump Tank GAL. Trench WidthatoL Rock Depth Linear Linear Ft p t Other: T10-3 -GoSG U-- L'"s '9 Required Site Modifications/Conditions: (JSTALL' (z C'-0-�nJ(Z �1 dF - log 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.**** LoT xi 9 t M�N,�►p' lOpt t D>L3 x12' I � 1& G ntiI.J, r+W. AP���.�D' PQ.oP,L1t•S� Lor ff 1 u Environmental Health Specialist's Signature: Date: l/ g� DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Bog 848/210 Hospital Street Mochsville,NC 27028 (336)751-8760 Account #: 989900025 Tax PIN/EH M 5789-76-5851.10 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Sec.1 Lot#10 Reference Name: Dick Anderson Location/Address: Peoples Creek Road 27006 Proposed Facility: Residence Property Size: 3/4 Acre ATC Number: 2216 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 WASTEWAT S TION IS VAI FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: X19 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. 12' ST !Qp 1 Septic System Installed By: 0+� Environmental Health Specialist's Signature: Date: f DCHD 05/99(Revised) EELICAT-ION FOR SITE EVALUATIONAMPROVEMENT PERMIT j� (� FJ4 Davie County Health Department " �1 Environmental Health Section P.O.Box 848 — 8 K Mocksville NC 27028 (7 3". ivxxx 760 ENVIRONMENTAL HEALTH ENVIR i Ps1E T HEALTH **** DAVIE COUNTY DAVIE r WMPOR T THIS APPLICATION CANNOT BE PROCESSED , ALL THE /REQUIRED INFORMATION IS PROVIDED. n 1. Name to be Billed /C& NOC28 D4)( 6W3 .-Z C . Contact Person -tele /-g"'-:CB D^/ Mailing Address 1-/4 t/4:-:it/ L A/. Home Phone City/State/Zip 'Moce S t//c -'6 C .27u 019 Business Phone l qqi-7.Z7q 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip '/a.N-'741 3. Application For: Site Evaluation X Improvement Permit&ATC ❑ Both 4, System to Serve: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms -3 # Bathrooms �{I Dishwasher Garbage Disposal 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? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A P AiVMTHE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: RAT Pe,4 / 6iY CwScO 1 WRITE DIRECTIONS(from Mocksville)TO PROPERTY: Tax Office PIN: # 7 g - — - 6-9' •5-% 1 1 /5 Tv 80 - -Ir6eA) Property Address: Road Name 1 IeTEV /-7o A City/Zip Ao,IAAAgg_ Al C d-loo G ' I If in Subdivision provide information,as follows: 1 K Name: /Y A i2 CH 0J0e)lis - 1 1 /Y)/(Fc—S Section: Lot #: �0 ' 1 LC/-S Dk Aa-. 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 inft ntation 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 Representative of the ,Davie �/County Health Department to enter upon above described property located in Davie County and owned by �/o�iV H. H 00 7—C to conduct all testing procedures as necessary to determine thesitesuitability. �7 DATE 6 6 — 7 SIGNATURE Revised DCHD(06-96) JOU MAY USE THE BACK OF THIS FORM FOR DRAWING YOUR SITE PLAN. �O YO --- % % A SIDNEY F. HOOTS' / ti D.B. 175 Pg. 507 IV 33.47.22• J 231.61 ' �----- �__ _✓� iti J ---- ..�`` �/ -�'' �,__ ems' �� ����`cl - #9 o / FI. HOOTS00 1\ \t906• r = . Oy-% % %/ ''•`�7= c. O p 75 Pg. 504 `�� \ 1 p1 9. \\ ) / L/T,,/7%' 110 ms' s r710 � N '��y3• f� ,`��/ / /- ` � `\`� \� \\\ ` , � `\ 1 \i I r���- /' �/ � '//// //, ,/ ;/ ,// // r � , IQ6 I 1 156 + 1 LOT #5 o / LOT 2 ' t LOT 1 -- j \. l < < oil " I" t-tj I MIGHT LOT .'!�,2 / . / • ile /i'• ;`�,L , / / \� -"t lso -- ---\ ' -lso — ty 14 to'x7o'SNZHT ^ -� ./ /�/ J:' i �,/ / :'�,---5 \\� -- � �• `• (PUBLIC)% J' / `� '-)- LOT '' %' / , ''' l/wT,.f I j % ' j /! ff,��, LAjo 1 1 I i / ♦ �I / i ` 1 I �1 i I i 1 i i i I / ���.� LOTil 1 n 1 j ru' $+ . V / / / 42_ 81 ♦ 1111 ► + r °' to Nil � -- 91 / t6T #23/ / \ / r 1 1 \ , + I 1 , , / LOT #1� 1 , / A 1+ 1 1 \ + 1 1 1 1 r1, I l t ; 1 i—••\ \` �"� ! 1 / iO I / I 1 _ / rto �� ►�li VOT `\ \� /''✓'OT' ?� i/, JIB I '; /;/ ` 11 \`+; ; �` 130 Ili q `fL ��'- -// - -/ i!!� !l r/ j I 1/ r � /� +1 \\ � �� 140 TS 10, 504 —10 �'// - �. ♦ �t� 1 6.71._ el , ♦1 -i , 7• M JA J t 01, / , --1, /�" -.29g — �� �' �,//�/ ;/�- —� /' /' NOTES / . / �. r^ / /, , / / / / / ,/�, 1. ALL LOTS ARE SUBJECT TO DANE COUNTY HEALTH DEPARTMENT STANDARDS. /• �__�" i \• / /� // /�•j ,l�/' �/ // / /1i r ' 2. ROADS ARE TO 8