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146 Old Farm Rd Lot 4 .4 v,�a ffi I. �y •ii` ,AUTHORIZATIGN NO: 1981 DAVIE COUNTY:HEALTH:DEPARTMENT - - )environmental Health Section. PROPERTY INFORMATION Perm�ttde . P.O.Box 848 Name �4, .e' t'f 10 Mock e,NC 27028 Subdivision Name: •+�`+ /� ��© r f Phone# 336-751-8760 Directions to property. v` (� Section: Lot: ' AUTHORIZATION FOR WASTEWATER .' Tax Office PIN: SYSTEM CONSTRUCTION L Road Name �� �= Zip: l Q � **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.]900 Sewage.Treatment and Disposal Systems) ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ✓;1;_ dGt/ t}'J �� IS VALID FOR A PERIOD OF FIVE YEARS.. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED tir �.'_' .*d 3 s�-r ' r •.i-' -+ -.rrfft.,_;r`;¢;. +„j.':+- ..._-.. - -,` ._ .--... ,.., .-.:.:-s+..a n+r -� ATH DEPARTMENT .. . �, . DAVIE C UNTY HE L .r 'ya ` {Y IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION . -Permittee's ;Subdivision Name. 'Direct otrs to property Section: + Lot: it IlVIPROVEMENT : PERMITTax Office PIN:# -R7 1.- DFf 11 Road Nam �fi e .' Zip: �� 1d N **NOTE**This Improvement Permit DOES NOT authorize the construction or installation of aseptic,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 SPECIALIST w 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 ' " DESIGN WASTEWATER FLOW(GPD) NEW SITE Y REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE• GAL. PUMP TANK GAL. TRENCH WIDTH ` /ROCK DEPTH e&; /:LINEAR FT. � OTHER REQUIRED SITE MODIFICATIONSkONDTTIONS: IMPROVEMENTPERMIT LAYOUT *APPROVED EFFLUER FILTER* *RISER(S) IF G*, UELOW FIUISHED ..GIIADE* tv "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 (336)751-8760. OPERATION PERMrr►0p SYSTE INSTALL BY: f��^'l�-• �LklG3� i .IdT AUTHORIZATION NO. u( OPERATION ITB DATE:' v "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE AS BEEN INSTALLE IN COMPLIANCE : WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAG ISPO AL S",BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR AN IVEN PERIOD O E. DCIM 05M(Revised) APPLICATION FOR SITE EVALUATION/II%IPROVEb1EN7'PERMIT& Davie County Health Department hh Environmental Health Section U 0 U P.O.Box 8.38 Mo(ksville NC 27028 ' 8 1998 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED NLESSVIRO HEALTH DAVI ENTAL E COUNTY ALI,THE REQUIRED INFORMATION IS PROVIDE D./� n 1. Name to be Billed /G� il(OC28 0��a(/S!.-..L C . Contact Person Ana Mailing Address o7a S 6d/N& 14q✓4r-,t/ LA/. Home Phone � �.' 7S7'7 City/State/Zip � OC,�S ✓n.e.,c . Al-L'. -2 70 a �' Business Phone _3-3/ qg�7x79 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 PXA5DXWTHE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: AT P4.4v 6/Y CC UScp 1 WRITE DIRECTIONS(from P� '0 sville)TO PROPERTY: Tax Office PIN: # :� 7 1 - - 6- •6t' /%�-JJ 1 !S-8 7v 8,01 - 79L,en Property Address: Road Name 40VAIVCea— City/Zip 4DVAAXE_ Al C d'700 6 ' n ' TZtjZN L/=1- p/V mit U/-u= 1 If in Subdivision provide information,as follows: / � � 1 �C Name: _MAi2C14 W�Dl�s 1 1 /1'I/CF1S Section: Lot #: 1 � G(Jcxx�s DAY �r . 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. 1,hereby,give consent to the Authorized Representative of the/D/avieCounty Health Department to enter upon above described property located in Davie County and owned by L�/�/l! H. Woo 7-,tz- to conduct all testing procedures as necessary to determine the site suitability. DATE 6 es 6 ^ 7 & SIGNATURE Revised DCHD(06-96) JOU MAY USE THE BACK OF THIS FORM FOR DRAWING YOUR SITE PLAN. 01 SIDNEY F. HOOTS / D.B. 175 Pg. 507 / .elk N 33.47'22• i - / Q4. ---------___� E 231.61 = �-- >Q / XO 6 ` lbO A. HOOTS \`� �J�0 o6. /' ,/ , ,7�i� I O O 75 Pg. 504110 l � t6T, .2� \ UB o7 �i i ,'� X111 6 /'� ' / i / ' , 0� 11 \�_ \� GJ " //" 'j 26. /N �� 93\` ��\♦moi/,�/� \ �` `\ ♦\ \\ ` �\ \\ I I "����/ /�' ' /l/ i / / / / /, i ' i i I�5 ' i + r 013L 770 LOT #5 ��� �` ♦♦ i�J ;\I 1 �\ \ \ 6� /� `_ ,i aoi LOT #t / / , r I 1 `� 1 ��--� — / 4,/�'1 a ' ,/ `° (xi LO 1in -----�'/ ' rl \ `\` \� _ I �/ T I / , �' sod\ �' ;ILO � �'� ,/ ' N I� ' I�N I �' LOT 2 ; 1 a r' 1 `� OT, (i., / / �� r r , / ,' • / % / / / / t LOT1 I /I 1 `� ' /.'�� �/ / /ti , 7: '� 1 1 1 p �` ` A X70'190FR rte' '( / 'S,\ ' , , kwSQWvP., b LO -T #17 /' l6leeA i / // LQT1, ' ��'///�'� /�.t` , ' / ��,` --`'\-150 — 150 '� -LOQ ' 1D'x70' SICHT (PUBLIC)♦ ♦ ' �1 / �EASQ1tM(7YP) ,' ,',' ,'// , —�—130— — r---- , , / , ' , \ r I \ ? LOT / ! r 1. - 1 LOT. 09 Ir 160T 0 � \ �r �./ \142 �/ 9 ,� I \ 1 I I �Il 1 i ' + i i + f ' `\�Z'-'cu l + a I r N ` 'nl 1 / / / l — 1 / + 1 \ 1 I I r --� 0 r `. / \' , 2 i I j' \i � 1 � r 1 � r I / , / I��N.` / T X23/ / �� �� - ' 1 ' ' 1 \ 1 I I r ; / LOT #1� ��) I 1 1 1 ` 1 r / N r/ '/ ;/ / ♦\ �� l7 , /A'OT 2 / ' ' rr l ' / ` 1 ` '1 ' ' �♦ / / !20 r LOT,#2 \ �� , .' /! r 130 I 1 1 �`` / / 140 , i N LZm� 140 TS 504 NOTES ? 61/ _ / - 'moi'- / ' / ' r / 1. ALL LOTS ARE SUBJECT TO DAVIE COUNTY HEALTH DEPARTMENT ST ANDARDS. 2. ROADS ARE TO BE BUi� ' i - EC U U E ,.^ Davie County Health-De ePR 2 9 ZOl 0 . 1 '_ Environmental Health S c n x; a ` ��'•I—� P.O. Box 848 ' "N11 " L' ENVIRONMENTAL HEALTH °ail `z ; 210 Hospital Street DAVfECOUNTY a�# Courier# : 09-40-06 r Mocksville, NC 27028 Phone:(336) -753-6780 Fax:(336)-753-1680 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection Name: _L) A• (tic..i�P-t=��� Phone Number " (v71 96z6 / Mailing Address: j CJ L'L' ��-+ fT��t/ yup � � X740 _7�S 2 - (Work)// ! il,J' A.)-C. ZZJG& /// Detailed Directions To Site: Property Address: 146 Please Fill In The FollowingInformationAbout The EXISTING Facility: Name System Installed Under: t j<_ AType Of Facility: !;2� '1 Date System Installed(Month/Date/Year): /p/tet Number Of Bedrooms:;3Number Of People: Is The Facility Currently Vacant? YesNo If Yes,For How Long?_ Any Known Problems? Yes No If Yes,Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: 74c c 4r,Gs is ' Number Of Bedrooms: Number of People 4 Requested By: Date Requested: ( gnatu ) For Environmental Health Office Use Only / :r:v Disapproved Comments: Environmental Health Specialist I&U,00 Date:S/S��OlO *The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee (extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cash h eck Money Order # SO Amount:$ /p2-ffl) Date: 11-2'7-10 Paid By: .Tools T ,�,N,` Received By: Q/?q Account#: SSa/ Invoice#: 7.30 p EcEoYE V Davie County Health De elP1 2 9 ¢. r ���. 2010 � I .�� ` Environmental Health S c n R P.O. Box 848 ENVIRO!N'MENTAL HEALTH 210 Hospital Street DAVIECOl1NIY , w s Courier# : 09-40-06 Mocksville, NC 27028 Phone:(336)-753-6780 Fax:(336)-753-1680 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection Name: A- Phone Number ' (o-j j• �?t72/. Mailing Address: (CJ� , `4Q rk :NVz Detailed Directions To Site: Property Address: 14(,::> . 0L_6�J� Please Fill In The Following(Information About The EXISTING Facility: Name System Installed Under: 61 J- <— A Type Of Facility: Z!"z"c5 i��� Date System Installed(Month/Date/Year): /O/C? Number Of Bedrooms: 3 Number Of People: Is The Facility Currently Vacant? Yes oNo If Yes,For How Long? Any Known Problems? Yes No If Yes,Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: 7AJA_i &L�t5-n Number Of Bedrooms: —3 Number of People Requested By: 7Q Date Requested: ( gnatu ) (//App:rov For Environmental Health Office Use Only Disapproved Comments: Environmental Health SpecialistDate: Z/51_ 2&0 *The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash heck Money Order # . / S'O Amount:$ /p2•&D —Date:—,'/-29/0 Paid By: .To+yo�C 're,w- Received By: QA Account#: SSO/ Invoice#: 7.30