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127 Old March Rd Lot 11 DAVIE COUNTY HEALTH DEPARTMENT ll'3�� vev Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT(OPERATION PERMIT Account M 989900025 Tax PIN/EH M 5789-76-5851.11 Billed To: Dick Anderson Constriction Subdivision Info: Marchwoods Sec.1 Lot#11 Reference Name: Dick Anderson Location/Address: Peoples Creek Road 27006 Proposed Facility: Residence Property Size: 314 Acre ATC Number. 2217 **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 +b05 f #People #Bedrooms 3 #Baths -2- Dishwasher: Dishwasher: M--"Garbage Disposal: 12"-Washing Machine: ETBasement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size V� )c-243S' Type Water Suppl.C-G'014Te Design Wastewater Flow(GPD) 3X00 Site: New Repair❑ System Specifications: Tank SizetQOOGAL. Pump Tank ICC)GAL. Trench Width s�"Rock Depth 12-� Linear Ft.--3�701 Other: —ts I,.1STb.LL Required Site Modifications/Conditions: Ge�Too Q_ {ZAP to o`-C 412oP, L4-1,55 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.**** A .,-60 SPL-� �- VI L0Co,Tt0,j Gam►-�(x� I i `to d hI I � r e ,w.9of �. %L4 %0 Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) DAME COUNTY HEALTH DEPARTMENT • Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 989900025 Tax PIN/EH#: 5789-76-5851.11 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Sec.1 Lot#11 Reference Name: Dick Anderson Location/Address: Peoples Creek Road 27006 Proposed Facility: Residence Property Size: 3/4 Acre ATC Number: 2217 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 I 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Trea ent and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATE N IS V ID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signatur Date: qR 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 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 sV factorily for any given period of time. a' l.t t,)0� fl,%5 ar r a Flo' ,Z s t Septic System Installed By: G L—&V-V Environmental Health Specialist's Signature. X,— e: 7 DCHD 05/99(Revised) AP TI N FOR SITE EVALUATION/IMPROVEMENT PERMITtFENVIRONMENTAL `-- 2 Davie County Health Department t5 a� , Environmental Health Section lP.O.Box 848 _ 8 10 Wj � Mocksville NC 27028 G9AITHVIE COUNTHY�LTHENVIRO 1AjIIPORTANT**** THIS APPLICATION CANNOT BE PROCESSED IE CO ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed o4)66W3 . -TMC . Contact Person Ane /gdJO't-ZW-2O'v Mailing Address o7aS UJ/ill6- t1,tE-:N Lit/. Home Phone A" 7S7'l City/State/Zip '&Ocoe s C .270 a. S' Business Phone. --34 lggg-7a 79 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: Site Evaluation W, Improvement Permit&ATC ❑ Both 4, System to Serve: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms _,3_ # Bathrooms AJ 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 tA No If yes,what type? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLATM THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: R�97- An1/ 6/Y CLUSC'o 1 WRITE DIRECTIONS(from Mocksville)TO PROPERTY: Tax Office PIN: # 4;--7 a - 7 6: - 6- -5-% 1 1 �SS �v ga/ - �•e.•cl Property Address: Road Name P�oDefja C��A-- 0Q0. 1 City/Zip ADVAAXE Al. C d-700 G ' ' Ute V GAI=T ON 1 If in Subdivision provide information,as follows: 1 K AQ 'q4oxyx Name: MA Q CH &VQe)d s 1 ' If, mica 7011'24,e204 Section: Lot #: �! 1 1 GClc s Dk !cr. 1 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 L/Of-l/l/ H. �C�U T� to conduct all testing procedures as necessary to determine the site suitability. DATE 6 — 6 es — 7 & SIGNATURE Revised DCHD(06-96) YOU MAY USE THE $ACK OF THIS FORM FOR DRAWINC7 YOUR SITE PLAN. �— /�yU --- ---" / / ej a SIDNEY F. HOOTS / m D.B. 175 Pg. 507 ----- / i' N 33.47'22• �O�\g QQ. 231.61 2 �' �� / �\ P�\Gl 0 -4. HOOTSJ _ � 75 Pg. 504 \. "" .00 •�Zg' \. / / LOj.'J7/•' /• //� ,� '/ r '170 - t�T' r�'• r \ \\ (p/'9 qi 1 _ '/ . �� --- ' ' '/ N 0. �53•I I 1` \� \1 \\ `� /' I I `� o `1 `✓ ,' /1"IL \ I`\ \\ J9p \\\ i i N – J 09L N 4141 \ LOT #5 LUI VLt6 OD I '�_1� \��-----�–�"�/ \ r \\ \� ``� `qtr ��/ % / f I ' \�•\ � ---�� J' .>�,�/i� 4/I / 1� / � /'/ � l i I i GS I Iv LO // I ` \` f i \ / `� SOS^\ ENT / / / / /V.0 N 1 0' N I Olr' 15' / / �� ' I / =�� ,/ , / ,/ / , , / LOT 2 I t LOT 1 1 liv �` ` 10'X70'MGHT LOT �jE17 i' J6 Bc' / i / �' / „r_ ' / , — 150 --� --�-15D 1— (PUBLIC)♦ 1 L/1 / fO7f70' SIOf(f , //� i/' ,//r i / //' / J `� ✓T-— .,. 1 � �— ore / LOT �–_ --� / �'� J �• ',/ . ��.' i � / / //�/ % � // I T ��— _ `� / `I;�4 ��, � � `\ �� \ it I tOT 1 / / I I / I , / / - I L&I #9 I I 1 LOT p 1 ,rl I / co �N N `\\\ �(` / T X23/ y�1 �-- rI 1 ' ' 1 \ ` I 1 1 I / LOT �l � ♦� �---- 1 I // '° Iii 0 �.° 'ZOT,42� 1 � ' i f / 1 �\ ' _-__ L / / II I N �/ VOT' 2 _ / / j �/! I I I / �/ / \\ \` \\ (\ < \. '130 i b i/ �/ // /' i/!� III/ i ' 1 / / '' /� TS / a LZ7T` 2 / .d' / / / / --o J , , �` 135 504 s.AA ��_ 1 1 \ NOTES ? 1. ALL LOTS ARE SUBJECT TO DAVIE COUNTY HEALTH DEPARTMENT STANDARDS. _------ ��---�- / 1 2. ROADS ARE TOB �SIf��