129 Holly Hill Ct Lot 19 THORIZA%TION NQ: `1921ADAVIE COUNTY HEALTH DEPARTMENT
Environm"ental Health Section PROPERTY INFORMATION
Permittee's / t� P O.:Box 848
'Name: J�!/%(�° � i ,'T .K m, 'Mocksville,NC 2701`8 Subdivision Name: ,
�� � ' ��
Phone.4 336-751-8760
Directions to property: 1 ''f Section:
Lot:
_ ,J ' . AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN:# - '
%! Road Name: Zip:
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of,any Building-Pem-ts,This Fomi/Authorization Number should be presented to the Davie County Building Inspections '
Office when applying for Building Permits:
(In corppliance with Article l 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
' ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FORA PERIOD OF FIVE YEARS.
ENVIRONMENTA�'H�EAL
ST DATE ISSUED'
! l t}
`1A DAVIE COUNTY HEALTH DEPARTMENT
` ? IMPROVEMENT AND OPERATI,ONPERMITS PROPERTY INFORMATION
Permittee's /
f�
P
Name: ' " �' `'� r'�' ,err r a t Subdivision Name
Directions to to property: • -gin'f ,r<�'rCSection: Lot: 4
f IMPROVEMENT .
PERMIT Tax Office PIN:# `i 2'- 2, -
.r. r 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--#BATHS_ #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLEISHIFr #SEATS INDUSTRIAL WASTE.Yes or No
LOT SIZE TYPE WATER SUPPLY _ DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE i N'
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH .S LINEAR FT
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
*APPROVED EFFLU FILTER* *RISER(S) IF 6" BELOW FINISHED GRADE*
t
PC
**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 RM.ON THE DAY OF INSTALLATION.TELEPHONE#IS(H14)fii48760:X
(336)751-060
OPERATION PERMIT
SYSTEM INSTALLED BY:W ` J
r
Dv
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
u��
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED 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)
DAVIE COUNTY HEALTH DEPARTMENT
t }, IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittee's `
F _
Name: �` _ Subdivision Name. F
Directions to ro ert i='�s '"" � ,`f �. Section: Lot:
r r y:
IMPROVEMENT f
1' PERMIT
• ,'. € r-.. 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 ry #BATHS—'7—#OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY^i� DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT*APPROVED EFFLUENT FILTER'S *RISER(S) IF 6" DELOU FINISHED GRADE*
. �
j A PF .
"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(7My634F1b6X
(336}7S1—El76td
OPERATION PERMIT
SYSTEM INSTALLED BY:
i
�r
" , I!'V'.i �
AUTHORIZATION NO. " t- f OPERATION PERMIT BY: DATE: ` Z
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED 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)
� L3 FUZATION NQ: 1479
DAVIE COUNTY HEALTH DEPARTMENT
';l Environmental Health Section PROPERTY INFORMATION
Permittee:a�, ,, P.O.Box 848, /h
Name:�► ► r Mocksville,NC 27028 Subdivision Name: / r/IOpC
Phone#:704-634-8760
Directions to property: Section: Lot:
AUTHORIZATION FOR
WASTEWATER
0 � 4
SYSTEM CONSTRUCTION TaxOffice PIN:#
Road Name-Re5'U' �K�4p:27006
**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. ;
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
t _ ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPheIALIST DATE ISSUED
14790
DAVIE COUNTY HEALTH DEPARTMENT
ti �, IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
P ittee's��
N me:`,a w;k ,� .R Fx4 ' `, 'd Subdivision Name: .� f �d/✓'t tet?� '�
Directions to property: Section: Lot:
IMPROVEMENT .�
PERMIT Tax Office PIN:# "•
Road Name: eU C�SI:.�`k�"` 16,2 p�
**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 1 I 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 #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLEISHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
**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 PERMIT
SYSTEM INSTALLED BY:
�v
AUTHORIZATION NO.--�I t�OPERATION PERMIT BY: Aa DATE:
L
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED 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)
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERM R p
Davie County Health Department Q l5 u
Environmental Health Section
P.O. Box 848 _ 8
Mocksville NC 27028 .
( 3 6)751-8760
%nRoNMEl`ffAI.HEALTH
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESS AVIE COUNTY
ALL THE REQUIRED INFORMATION IS PROVIDED.
/� n
1. Name to be Billed /C',� QNDC28 O.()`/6jS%._L C . Contact Person Ana /-fd/OtiEW—$ew
Mailing Address W/ill G- 47 Al Z Al. Home Phone ��" 7S-7-7
City/State/Zip �moce-5 ✓!C -'a . ,/1/.�. � 7lJ a �` Business Phone 3 qq8-7. ,7 7
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: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms -3 # 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 P.YA iDMTHE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: RST plgy 'g/v CLoSc' 1 WRITE DIRECTIONS(from
1 Mocksville)TO PROPERTY:
Tax Office PIN: # S 7 k 7 - - 5-9' •S% 1
1 l 5-8 TU 8,0 ' 7r�&e�
Property Address: Road Name � UL�LF�3 CiPlt" K �O_ 1
1 /2T /-7o A
City/Zip AD✓A '.E_ C a'70O G 1
1 7Zcl2�1/ L f=r CA/
1
If in Subdivision provide information,as follows: 1
1 &
Name: MAi2CN WOOys 1
1 n'JicEa
1
. Section: Lot #: 1
1 G(J QW/2r
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 ,M H. Woo T--,c- to conduct all testing procedures
as necessary to determine the site suitability.
DATE 6 (• r V& SIGNATURE
Revised DCHD(06-96)
JOU MAY USE THE 13ACK OF THIS FORM FOR DRAWING YOUR SITE PLAN.
SIDNEY F. HOOTS /
q h ti D.B. 175 P . /
.. 507 �
9
N 33.47'22- E 231.61 ! �' ,�-'-- // e g Qq* '
e• cl
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e
#
s O � /
A. HOOTS \ f-1000
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115 Pg. 504 \� / °is' \ LOT,/#7-'
111-7
\ 1
'i70
J
--� \1 \ evC 7y �i i ,�- #6
!
-170
N 4!'q3. ` / `\\� \� \ 1 1 \ I � � l/ ! i l l ! ! I 1 6
LOT #5/�
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OT,415' ,/� %�� I I ! x` ./ % ;/ / i / i /� LOT 2 � t LOT 91 10,
tin
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LOT #17 /' /6c'e� �' '//LO i�` -
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LOT % `---�, ---�-- ' r—
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LOT LOT9
ho
X142 / / ,�/ j 1\ 1 ( 11 i i I i i I I rt �`\` LOTil 1 I n i N \
e1 II \11 1 I I I I ! � `�� �N 1 a / ` I
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�T #23/ ' \ AD'S / i' ( \� 1' i i I I I i ! LOT
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04
1 ,
�1-4
NOTES
61/ �
61/ ALL LOTS ARE SUBJECT TO DAVE COUNTY
HEALTH DEPARTMENT STANDARDS.
2./! ROAD ARE E TO BE BUILT TO NCDOT STANDARDS
BEING A PUBLIC ROAD WITH A 60' RIGHT-OF-WAY
,
/ / ,
• DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME PHONE NUMBER
ADDRESS CT SUBDIVISION NAME_V_)__V-AR-CA �dS
LOT#
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING_ -
DATE REQUESTED INFORMATION TAKEN BY �-
This is to certify that the information provided is correct to the best of my knowledge,and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93