130 Holly Hill Ct Lot 20 AO',, �12ATJON NO: DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permitiee's i P.O.Box 848
Name: Mocksville,NC 27028. Subdivision Name:
Phone#:704-634-8760
Directions to property: Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
M CONSTRUCTION. - ,f
SYSTEM ,f�
Road Name: 1"e0�� l:Rk Zip'A706
**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 I 1 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
4 '" 461 DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Name: n Subdivision Name: �'` ��
Directions to property: .'`f`el . / . r� �' Section: Lot:
-`
)rte
PERMIT Tax Office PIN:#*let l� ! r � �1f
°]t3adName:
**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)
1 f -,a,, ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
41- {�~;� 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 1 #BEDROOMS yL_#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 Gy DESIGN WASTEWATER FLOW(GPD) Ay NEW SITE r REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE 20PD GGAL. PUMP TANK 1 GAL. TRENCH WIDTH ROCK DEPTH ALV LINEAR Fr.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVES NT PERMIT LAYOUT
ov-
l s ,
4
"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:
AUTHORIZATION NO. OPERATION PERM �/
DA
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 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 EVALUATIONAMPROVEMENT PERMI
-~ Davie County Health Department 0 r'
Environmental Health Section
P.O.Box 848 JUN - 8 1
Mocksville NC 27028
998
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESS
ALL THE REQUIRED INFORMATION IS PROVIDED./'� n
1. Name to be Billed /G� NDC28 O.()LULU_Sr. C. Contact Person-��C/ft/t7 $Dil/
Mailing Address o7a S mil/A16- 1-47(142—Al LA/, Home Phone ' 7S-7 l
City/State/Zip �MQC.e S VILC-6 , Al.C y2 70 a f Business Phone 3-3�/gq��7a71
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 Z—
AI 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: X 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=TMTHE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: RA7— 00e qAl 9/Y CC.0Sca 1 WRITE DIRECTIONS(from
Mocksville)TO PROPERTY:
Tax Office PIN: #
1 !S8 7v
Property Address: Road Name P'—=Q10 ES Cir2A;e—e-- 1QD" 1
AE�'- 40 A
city/zip AD>l1qA4-=—. Al �' d'7o o G '
' 7ZUZN 449,=,7—cnV
1
If in Subdivision provide information,as follows: 1
1C, stG D
Name: �Ai2 CN LCI�D Ids 1 I
1Z Inizisa
Section: Lot #: � '
� GClcxx�s DAA�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 Woo T'S to conduct all testing procedures
as necessary to determine the site suitability.
DATE 6 49 — q9- SIGNATURE
Revised DCHD(06-96)
YOU AtAy USE THE BACK OF THIS FORM FOR DRAWING YOUR SITE PLAN.
SIDNEY F. HOOTS
P 175 D.B.
.. 507
o r
------_ / i' N 33.47'22- E Qo.
231.61
#g
A. HOOTS ``.� \14200
'5 Pg. 504 \. �/ \ °Zs' \. / / LOT,'#7,''
N, , q \�/ ( �//' 110
�v #6' 0 1133'1 I i 1 I J_
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770n l \ �\ a0 �\\ I r l—' oY 09
N 414!\93��\ \` '/' � `\ `\ \\ \ \ I I �'J����' ,' ' % i 11 i 1 6
LOT #5 / % ' l i r 1 I
jl i �l /,/ %ll) 1361
OD I
LOT 2 I a i
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LOT *l7 '' Jsc' 2 /'' Wf i, ' /�' / / \` —"\150 --` --T150 �— v
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/ t6T #23 � ------ \ I I � I ,
It \ % 1 III ' 1 LOT 1 � , 1
it
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N �/ LOT 2 `. / '� '/ / `\ ,\ \� `\ <` \.\ �—'J '13040
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.' ✓d ��' / / i � \ 140
/� 135
Al
NOT
61/
'
61/ _ / / / i/ / ,� 1. ALL LOTS ARE SUBJECT TO DAVIE COUNTY
�I/ i/ ,/ �/ /"—��' '///// //� ��/�^_��'/ �•'i/ /i f l I 1 /' HEALTH DEPARTMENT STANDARDS.
2. ROADS ARE TO BE BUIL-T TO
NCDOT/�'' / BEING A, PUBLIC ROAD WITH RIGHTOF-WAY