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135 Old March Rd Lot 12 _ DAVIE COUNTY HEALTH DEPARTMENT / Environmental Health Section �D T P.O:Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900025 Tax PIN/EH#: 5789-76-5851 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Sec.1 Lot#12 Reference Name: Dick Anderson Location/Address: Peoples Creek Road 27006 Proposed Facility: Residence Property Size: 3/4 Acre ATC Number: 2239 **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 CONTRAS/CTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People #Bedrooms �,-? #Baths Dishwasher:JRr Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: 13 Basement/No Plumbing: O Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: Lot Size Type Water Supply Design Wastewater Flow(GPD) �.�� Site: New ET/ Repair System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width V !Rock Depth /Linear Ft. 6p Other: Required Site Modifications/Conditions: 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.**** 1= Environmental Health Specialist's Signature: / Date: DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 989900025 Tax PIN/EH#: 5789-76-5851 Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Sec.1 Lot#12 Reference Name: Dick Anderson Location/Address: Peoples Creek Road 27006 Proposed Facility: Residence Property Size: 314 Acre ATC Number: 2239 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 WASTEWATAR CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: I�f� Date: 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. F Septic System Installed By: Environmental Health Specialist's Signature: Date: �� DCHD 05/99(Revised) APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT&ATC Davie County Health Department (� Environmental Health Section D P.O. Box 848 Mocksville NC 27028 J 8 19M (7 3 6)751-8760 tt ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSE UNL %'A IE COU!M j� ALL THE REQUIRED INFORMATION IS PROV D. 1. Name to be Billed AC& iVDC'/2B O.J C QuUS%.-Z C . Contact Person --AMG 4V,01-E�CB DA/ Mailing Address Gt IA16- 14 t/rAl LA/. Home Phone �Q:�" 7S 7 9 City/State/Zip �M,2C.&s v/est . AL C .270 a i' Business Phone 3-3/-ZqV-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: House , ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms -3 # Bathrooms Dishwasher X 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 Ilk No If yes,what type? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PXAiVMTHE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: X« jg/V CC.UScp 1 WRITE DIRECTIONS(from 1 Mocksville)TO PROPERTY: Tax Office PIN: # S7 - -7 6 % 1 /S8 Tv 8a1 - 74W-A) Property Address: Road Name PO . 1 1 A�'- 40 A City/Zip ADV'gA'c.E. Al. C a-loo ' ' 7&.t A/ Ls=r- pn/ 1 If in Subdivision provide information,as follows: �/� 1 K Name: 1L2 micEs Section: Lot #: 641- 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/D!-,//V H. I-Loo T-r' to conduct all testing procedures as necessary to determine the site suitability. DATE 6 "- 6 ^ V& SIGNATURE Revised DCHD(06-96) YOU AIAY USE THE 13ACK OF THIS FORM FOR DRAWINta YOUR SITE PLAN. �1117Z- -- SIDNEY F. HOOTS D.B. 175 Pg. 507 - / N 33.47'22• -------- J 2 E 231.61 A. /----- _ � i� I_------� / '� -- ems/ % �.►�'`,� HOOTS so� Q7 1 / 75 Pg. 50 \ o� \� / /LO 110 SAO -#626. 141 9\` `1\ �✓ // �Rr O9 LOT #5 t` _ nj co I s Lal -� ` � --- 1/'r � \ ` ` ��-• _ / 1 ,�150� r � � i J , eco N o . LOT 2 I 1 a OL41�' / j \\ ' I , ��,` ,� ,/ , / •/ / , / , r/ ( LOT 1 I :r / WGHT 8133 LOTf17 -�' l6�;eA � //'/�/ �/ ' jam/ / ��/ , ' / r, �� _ \ \\150 --� --x-150 1— tzl __LO� ^ / \ (PUBLIC) ' v1 LOT ',' ,' / �j ;. ,� , I r ' ?^ _---� �/ R�• . / ,� / � / / / ,r , /, , /' __---- �]X�,, / I I 1 � �\ '1 I Fes, T // j j \` (/t'oT/�1 / j / ,/ / i i I j i , / ,�"_ I LOT, #9 I I 1 ,/ ��,� � �• � �' J � 1 1 1 I I I I .� -, LOT N ' \ 142 / \ 1 11 1 I 1 I , 1 I ' / ��_ N t, I n / I . I yl1 X11 1 I I I I I r � � ( N r 174.0 - � �� Ic , \ /' r 1 1 \ I LOT 1, 1 � �T 23/ / � \ 1 I , � / \ Ajy / 1 , 'I r"� /Z'T /r 142 r, \�\ J y I N / VOT 2 �� / �'' /1 r I / /' �\ `\ \� �\ II < n Z. - '130 , Ij 140 ,/ /',/ .� / / /� --� 140 TS �' ,/ / ' �/ / l / /�i / r / /�135 504 ,/' // - /,� /1 — %�/�� /%/ j,/ �!!,� 1y 7,,a 1 6 1 - i' loll NOTES NOTES / r -z� ,/� j� /' 1. ALL LOTS ARE SUBJECT To DAVIE COUNTY I /.'/' HEALTH DEPARTMENT STANDARDS ROADS ARE TOB