166 Old March Rd Lot 6 AUN60Z,ATION NO DAVIE OUNTY HEALTHDEPARTMENT.
183
Environmental Health Section PROPERTY INFORMATION
Permtttee's /. 'P.O.Box 848
Name: ltGr '� / � � ' 1�,I• - Mocksville,NC 27028 Subdivision Name: rte/ 'fir'
Phone# 336-751-8760 .r
Directions to property: %,f /Y�',�'.� Section: +` Lot:
AUTHORIZATION FOR /
WASTEWATER Tax Office.PIN:#.:57 �4- � F
SYSTEM CONSTRUCTION .
Road Name: v ��
�It'
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County,Enyironmental Health Section prior
to issuance of any Building Permits.This Form/AuthorizationNumber 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)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF.FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
41 r�+-Lt--.w_r '.:yy� y.fja.s f .��►+i'a•. Ff,a �,�" `6 - ... .-. - -'-.� _ - L. •-.. ..� -F-t 1Z;,of
"Z -DAVIE OUNTY HEALTH DEPARTMENT
�,.� JMPRO EMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permlttee's' ,
l /�( 1. 1t ,, .
Nttme: �C A ,- t`• - Subdivision Name:, w
Directions to property y- Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:4!5�,
Road Name
**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 Departm t prior to the
constructionrinstallation of a system or the issuance of a building pen-nit.
(In compliance,widi Article:I l of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
.f f
***NOTICE***THIS PERMIT 1S 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 #PEOPLE/SHIFT /a #SEATS /INDUSTRIAL WASTE:Yes or No
LOT SI¢E TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD)�b v NEW REPAIR SITE
,SYSTEM SPECIFICATIONS: TANK SIZE/Wi_GAL. PUMP TANK GAL. TRENCH WIDTH_ ROCK DEPTH LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
t
**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
lSYSTEM INSTALLED BY:
moo' �� 70
a ''r
1.- rN�
z�
AUTHORIZATION NO. OPERATION PERMIT BY: -�� DATE:'/0
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICA THAT DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE i I 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 05196(Revised)
y"'01 .`•`"R'a'+"'i I,'�+, --r t:', c- :."3� �'1'yJ :.1 -htr ., .r _
C
DAVIE COUNTY HEALTH DEPARTMENT
�1r IMPROV EMENT AND OPERATION PERMITS PROPERTY INFORMATION
Name: ' �� ' '� Subdivision Name f� `t'f^! " ...'
Directions to property: Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#'
Road Namer %a�L3p:'° i
**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
constructionitinstallation 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***TILS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE TIHS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE_ #BEDROOMS–,7—#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 koo� REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE//1'�/; GAL. PUMP TANK GAL. TRENCH WIDTH,�y ROCK DEPTH- �LINEAR FT.5
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 (336)751-8760.
OPERATION PERMIT /
1 SYSTEM INSTALLED BY: ��/' L.e./n_Ll
Ii
701 � 701 A140t_ 6- 7-oZ)
i
� �k
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT. DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 1 I OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY iE 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 PERMIT&ATC
Davie County Health Department 12 ❑R
Environmental Health Section D tS `r,
P.O. Box 848
Mocksville NC 27028 J — 8 1998
�jf( 360
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSF. UNL�YgRONMENTAL HEALTH
DAVIE COUNTY
ALL THE REQUIRED INFORMATION IS PROVI nn
1. Name to be Billed ,1/G� ,V
1. D.()�Q.{13r..Z V7 ,C . Contact Person AnC /g4J'0itE;C$0W
Mailing Address d a S 601il1Cr4✓r-it/ LA/. Home Phone - 7S-7-7
City/State/Zip �MOC&Z ✓lC.C,C . �.C .27ya S' Business Phone 334 lqqi-7a7q
2. Name on Permit/ATC if Different than Above
Mailing Address CWtate/Zi
3. Application For: Site Evaluation lsl Imovement Permit&ATC ❑ Both
4. System to Serve: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms _,3 # Bathrooms
9 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 PXA'DCIRTHE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: RST P4,eW xg/P CCOScQi I WRITE DIRECTIONS(from
Tax Office PIN: # S_7 k, - ^ - -8 -5- e*P)ocksville)TO PROPERTY:
1 /.58 Tv gai - C.e.tl
Property Address: Road Name J-c— ,O�a rPAO—=A-- PQ. I
I ieT ra /-7o A
City/Zip ADVA•t)cg -700 G 1
1
If in Subdivision provide information,as follows: 1
� � / 1 K
V
Name: _MA"ecw C/ ODfls
I micEs
Section: Lot #: 1
1
eZl D.' /c3-.
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 Davie County Health Department to enter upon above described property located in Davie County
H.
and owned by /D�{!V CSO T'-c,- to conduct all testing procedures
as necessary to determine the site suitability.
DATE 6 — SIGNATURE
Revised DCHD(06-96)
JOU AIAJ USE THE BACK OF THIS FORAI FOR DRAWING YOUR SITE PLAN.
--- j j C.,d SIDNEY F. HOOTS /
D.B. 175 Pg. 507 / .e'
N 33.47'22' E �r _ s"1_�''� / Qq•`�
_ 231.61 / AD 0
P0'Gl
,'/ ---- `_ _J/' �, � ------,� i/ '� �'-- ems, � �`►�'`'� I,
-4. HOOTS
75 Pg. 504 LOj.'�f7'' 't T / /• ,/ /��/��
'
110
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LOT 2 I ► LOT �l i b
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/ LOT � / , / / / / ' . \ r I �r' � . ?
,/ / / / 'fir
T
LOT 1 / / r r 1 I r / 1 LOTS #9 I I 1
r I i I I I I — LOT #11 ,n / i Mkn
142_ // 91 ,' I \ 1 vl I X11 1 �1 1 ; I I r `\���\N ` N I to ` I nl
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140
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TS
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NOTES
61/ ALL LOTS ARE SUBJECT TO DAME COUNN
HEALTH DEPARTMENT STANDARDS.
I /
2. ROADS ARE TO BE BUILL-1 _