126 Holly Hill Ct Lot 21 4kv,L�YFt{.� 1 4,-4T
Athflf,}F ATION NO: $ DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section., PROPERTY INFORMATION
-Pee,s P.O.Box 848
Name: ' Mocksville,NC 27028 Subdivision Name: _� `• l�;a�L1"'
Phone#:704-634=8760
Directions to property: Section: Lot: r
AUTHORIZATION FOR .
` - �J/
WASTEWATER Tax Office PIN:# �j J
SYSTEM CONSTRUCTION
Road Named o�i(t� E t. jl; Zip:
**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.
(Incompliance 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 HEALTH SPECIALIST DATE ISSUED
k+,�; g •t `.",{ "t,•` t t _.� _ f i �. �i y.J i. i 4..s
{f' 1°4 DAVIE COUNTY HEALTH DEPARTMENT
d� k IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
. PermjttAe'st
Name: ,' !.�'. ,,� �r.,' S.��'-s Subdivision Name:
odo'property: Section: L
f ,� " •'�%�r''> t�. ". ,
� +� ot: ��.
Dlieetis t
IMPROVEMENT
Y "PERMIT Tax Office PIN:# rl rl.
Road Name. i 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 CONSTRUCTION must be obtained from this Department prior.to the
construction/mstallation 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
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPE IALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS _#BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
'COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY ( Q DESIGN WASTEWATER FLOW(GPD)�—L6 NEW SITE ✓ REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE•o GAL. PUMP TANK GAL. ,TRENCH WIDTH 73G ROCK DEPTH.X� LINEAR FT.
• OTHER ,
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
-j
"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(704)6348760.
OPERATION PERMIT
``nR SYSTEM INSTALLED BY:
F
._ Q"70,r .
'�LI 'Jffi C,0,,A,4 i A r
AUTHORIZATION NO. OPERATION PERMIT BY: DATE: "r
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT YSTEM DES RIB ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I i 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.
DCHD 05/96(Revised)
e,
1482 DAVIE COUNTY HEALTH DEPARTMENT
.c •� �„,= IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
`Perm de's
X/ Subdivision Name ." ' t_• : '�''r+. r"
Directions[O-property: +' fir' �" r Section: `+d{ + Lot: i
P P y:
" IMPROVEMENT
PERMIT Tax Office PIN:# -
Road Name 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 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)
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS I #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT - #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY r DESIGN WASTEWATER FLOW(GPD)' NEW SITE "" 'REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE�GAL. PUMP TANK GAL�lTRENCH WIDTH Gf-•ROCK DEPTH LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
11d
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(704)634-8760.
OPERATION PERMrT(,V SYSTEM INSTALLED BY: t `•-�A�—t%�
`i�
7�
o'
0�
'°""''G1 r•a ►�� t,oM.P�+�>-r A-r ,SSP
AUTHORIZATION NO. ' t�z OPERATION PERMIT BY: DATE: 7 t
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT YSTEM DESCRIB ABOVE 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.
DCHD 05)96(Revised)
_. N
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PER
• Davie County Health Department D 1155 U IS
Environmental Health Section ��p
P.O. Box 848 JUN ' 8 Ko
Mocksville NC 27028
x
Fin
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCES
ALL THE REQUIRED INFORMATION IS PROVIDED./'�� n
1. Name to be Billed /� NDCi28 o )(r, LWS!.TNC . Contact Person —A /
x, "'-:'.'W
Mailing Address o70�S �� N6- 1-4,14E-AI ZA/. Home Phone 7-dW 7s TF
City/State/Zip BMOC&S VlLf.0 ) Al.C .270 o2 Business Phone /M-7a79
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: Site Evaluation ❑ Improvement Permit&ATC ❑ Both
4, System to Serve: K House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms _ # Bathrooms
ADishwasher 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?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED:. ***IMPORTANT***A PY.WDRTHE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: 8,97— 004-SV E/V CG.O.Sc, i WRITE DIRECTIONS(from
1 Mocksville)TO PROPERTY:
Tax Office PIN: # _;-7 7 - - 5-9' S / 1
/S8 TU $Q/ - 72%R-A)
Property Address: Road Name p'-oo« a P,D . 1
1 ieT 1-7O A
City/Zip A0VA1X-X= (/. C a'7o o 6 ' �J
1
If in Subdivision provide information,as follows: 1
1 K
Name: 04,X14 WODDS 1
1m«.a
Section: � � Lot #: 1
70 1177462cd
i UCIQQS DAY �r
This is to certify that the information provided is correct to the best of my knowledge. 1 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.1,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
ff
and owned by /Of-/�V H OU Es to conduct all testing procedures
as necessary to determine the site suitability.
DATE 6 - 6 — 479- SIGNATURE
Revised DCHD(06-96)
JOU AtAtY USE THE BACK OF THIS FORM FOR DRAWING YOUR SITE PLAN. 17PP•#v?�
�AIV,;0 7
SIDNEY F. HOOTS /
D.B. 175 Pg. 507
N 33.47'22• E 231.61 ,1 / p&,
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NOTES /
d
61/ �, // ./,� _ /moi / / // / /� / .� 1. ALL LOTS ARE SUBJECT TO DAVIE COUNTY
HEALTH DEPARTMENT STANDARDS.
2. ROADS ARE TO BE BUILT TO NCDOT STANDARDS
' BEING A PUBLIC ROAD WITH A 80' RIGHT-OF-WAY