157 Old March Rd Lot 14 P Tniw—s / / DAVIE COUNTY HEALTH DEPARTMENT
1,4 Environmental Health Section PROPERTY INFORMATION
P.O..Box 848. . E ,t
ry. Directions o property: !3.t�� eL /,7A/F Mocksville,NC 27028 Subdivision Name:
Phone#:336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN: 7
SYSTEM CONSTRUCTION '
AUTHORIZATION NO: 2323 A 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 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
t1 n✓ .Sx IS VALID FOR A PERIOD_ OF FIVE YEARS.
ENVIRO MENTAL 14EALTH SPECIALIST DATE ISSUED
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 REPAIR SITE ,
- SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK_____GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. Q
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: �f
Sv ....�
IMPROVEMENT PERMIT LAYOUT
r
**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 PERMIT
SYSTEM INSTALLED BY:
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
**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 02/02(Revised)
7r&4 i�
pDAVIE COUNTY HEALTH DEPARTMENT
Mta -.f-.•°
j is . �f'! Environmental Health Section PROPERTY INFORMATION
M -� . P.O. Box 848
Diletioirsta property: t' r:' /1 >>e: �gocksville,NC 27028 Subdivision Name: e'•`� �' -
-- r - �' Phone#:336-751-8760 j
Section: ! Lot:
- AUTHORIZATION FOR
WASTEWATER Tax Office PIN: 78
SYSTEM CONSTRUCTION
AUTHORIZATION NO: J;*"23 A 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 Permits.This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(in compliance with Article l l of G.S.Chapter 130A,Wastewater Systems;Section.1900 Sewage Treatment and Disposal Systems)
�i ,,r' ter/ ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
K.bj "�'i ':� �' i f t IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL 14EALTH SPECIALIST DATE ISSUED-
RESIDENTIAL
SSUEDRESIDENTIAL 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 REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH_ ROCK DEPTH LINEAR FT. `
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: --
IMPROVEMENT PERMIT LAYOUT
amara /Ql.�
"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 PERMIT
SYSTEM INSTALLED BY:
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
**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 02/02(Revised
O�n '✓ /o I
tv.a `'t'� � �«y;y o,,... . ,b �:,3 a ,i�F`-°'.t•^its ti+.,.t. �.:,,..^i-t a ;s, sA,,•-„'_ ---�,.,-e r..-,.-.. _r..��,+ y _ '
R,,.1�.�y;r.. jtt►'�ti.f�'it.�t..t;'r`£i't+�}1•.c...Fr�?twkf�'..y�4� .,.�i.y'a%�r �' ��s < �i i,� .
;ZATION NO 3 8 DAVIE COUNTY HEALTH DEPARTMENT eel �O
Environmental Health Section PROPERTY INFORMATION
-Pe _Ittee's Y ` / P.O.Box 848
Name: ,rel. - 41 ..' Mocksville,NC 27028 Subdivision Name: htln
Phone# 336-751-8760 /
Directions to property: i''l%r n< rf�'�� Section: f Lot: r _
• AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#SJ 7z
SYSTEM CONSTRUCTION -
Road Name:
**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/AuthorizatiorrNumber should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with:Article I l of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
- iG!J.1'' �t�/ >�T�• ��% IS VALID FOR A PERIOD OF FIVE YEARS.
'A� _ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
ri{!.°.. +JL�'a�,tJ'rf s'J'Ltr r..4�•-p J `'yk� 'i y ,.ts.i'J'', ' at.t ,.f.r ,...,..:<•t..-�,..,. � .v .-- ^. •r - ..
DAME COUNTYHEALTH DEPARTMENT
` IMPRO EMENT AND:OPERATION PERMITS PROPERTY INFORMATION
tees
-Name.- Subdivision Name: .�' e"3 '
Directi ns to property: r"` Section: Lot: e r
IMPROVEMENT
PERMIT Tax Office PIN:
r
Road Name. in
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of aseptic tank system or anywastewater system.An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained fr6m this Department prior to the .
constcuction/mstallation of a system or the issuance of a building pernut.
(Incompliance with Article 1 I of G.S.Chapter.130A,Wastewater Systems,Section:1900 Sewage Treatment and Disposal Systems)
, ✓, �, *- l�f� f ***NOTICE***TILS PERMIT IS SUBJECT TO REVOCATION IF SITE
k � -f µ, ./6f a l ✓ , , � 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 t #BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMIsRCIAL SPECIFICATION: FACILITY TYPE` #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIALWAS
+ TE:Yes or No
LOT SIZE ' TYPE WATER SUPPLY ( ll DESIGN WASTEWATER FLOW(GPD) b NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE _GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH �� LINEAR FT.
OTHER
REQUIRED SITE MODIFICA'T'IONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
• i
"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 PERMIT
SYSTEM INSTALLED BY00 :
K
OPERATION PERMIT BY: DATE:
AUTHORIZATION NO.--�� �'-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.
IxTTD051%(Revised)
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT&ATC
• 40 Davie County Health Department
Environmental Health Section D U
P.O. Box 848
Mocksville NC27� JUN — 8 til
( 3 6)751-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSEI UNLESSRONMENTAL HEALTH
ALL THE REQUIRED- INFORMATION IS PROV . DAVIE COUNTY
1. Name to be Billed / NDf-/28 O..)CL'w3%.Z1 C . Contact Person Ael,
Mailing Address o7a S WIN6- I- t/r-Al Z A/. Home Phone -7S7'7
City/State/Zip .&QC. -S V/C__,E C 2 70a S' Business Phone 334 gL7,9-7x7`1
2. Name on Permit/ATC if Different than Above
Mailing Address Cit tate/Zip
i Z.yz ����113sa
3. Application For: K Site Evaluation Ja Improvement Permit&ATC ❑ Both
4, System to Serve: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms ,�_ # Bathrooms �—
ADishwasher X 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 PlUkUM THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: R�47- Pe•4V 6/V CLUSc, 1 WRITE DIRECTIONS(from
MgCksville)TO PROPERTY:
Tax Office PIN: # 7 g - 6 - 6 S / J
Property Address: Road Name /
/�•caDC'F—A( i?seAe P.O_
City/Zip ADV44, '.E A C
1
If in Subdivision provide information,as follows:
1 K
Name: M'4 i2 CN won/o.,:-
Section:
on/osSection: Lot #' 1 '
1
G( s DAY
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 rngzS! 1`,f/. C)C)T<- to conduct all testing procedures
as necessary to determine the site suitability.n
DATE ` — G ^ 7 & SIGNATURE
Revised DCHD(06-96)
JOU MAY USE THE BACK OF THIS FORM FOR DRAWING YOUR SITE PLAN. � ' AO
4-AV, -78"3 d
/ / d SIDNEY F. HOOTS
D.B. 175 Pg. 507
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/' / / _ _ _-____ ♦ //
/ / i , // / / / / / ,/�. 1. ALL LOTS XZE SUBJECT TO DAVIE COUNTY
HEALTH STANOINZDS
EPARTAIENT�-'��'/ ;:,, ;,� //��, �i/ I 2. ROADS ARE I
11J TO
�
Davie County Health Department
4:�his I'(� Environmental Health Section _
P.O. Box 848
210 Hospital Street
O U '� Courier#: 09-40-06
Mocksville, NC 27028
Phone:(336)-753-6780 Far:(336)-753-1680
February 2,2010
Subject: Lot#14, 157 Old March Road
TAX/PIN#:5789-76-5851
To Whom It May Concern:
On December 22, 1998 a representative from our office issued a permit to Dick Anderson
Construction, on Lot#14 for a 3 bedroom residence,now 157 Old March Road. On December
9, 1999 the final operation permit was completed.
Then on March 29, 2004, the home owner or some other source called to have an issue
evaluated. As a result of the re-evaluation, a repair permit#2323 was issued for a 3 bedroom
residence. However, our records indicate that the repair was never completed. This permit is
still valid, though it will require revision to meet current rules. The permit will expire March
29th 2012.
No other problems have been documented.
Lam'
Robert Nations, REHS
bl/RN