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179 Old March Rd Lot 16 DAVIE COUNTY HEALTH DEPARTMENT � ��G Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900025 Tax PIN/EH M 5789-76-5851.16 Billed To: Dick Anderson Construction Subdivision Info: �fi16o�c 1 Lot#16 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27006 Proposed Facility: Residence Property Size: 3/4 Acre **NOTES* i bfmprovem t/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 CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People #Bedrooms ? #Baths Dishwasher: PT"' Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste:❑ Lot Size Type Water Supply_� Design Wastewater Flow(GPD) Site: New Ef Repair❑ System Specifications: Tank Size,_GAL. Pump Tank GAL. Trench Width Rock Dept Linear Ft.0,01) Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6 u 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.**** Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 989900025 Tax PIN/EH#: 578�9-76-5851.16 2 Billed To: Dick Anderson Construction Subdivision Info: -=- w 4 Sec.1 Lot#16 Reference Name: Dick Anderson Location/Address: Peoples Creek Road-27006 Proposed Facility: Residence Property Size: 3/4 Acre ATC Number. 2363 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 WASTEWATER ONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: "/ Date: al —V.? 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. let w l,f bvl Septic System Installed By: Environmental Health Specialist's Signature: Date: a/ DCHD 05/99(Revised) . .� APPLICATION FOR SITE EVALUATION/IMPROVENIENT PERMIT& Davie County Health Department D IJ U Environmental Health Section P.O.Box 848 J - 8 19W Mocksville NC 27028X ( 3 6 j 751 0 MIRON&WITAL HEALTy w ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED DAVIE UnW ALL THE REQUIRED INFORMATION IS PROVIDED./'�'� n 1. Name to be Billed Ace 4NnOf /28 0�LELt 3 -Zl e . Contact Person —1-11, g, Mailing $DNS Mailing Address o7a S WING- 14 4✓i Al 4/. Home Phone City/State/Zip _&0CJ--5 ✓!C-L,= , N.C .2 70-Z Business Phone 3 qqg-702,79 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: Site Evaluation (?, Improvement Permit&ATC ElBoth 4. System to Serve: House ElMobile Home ❑l Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms - # Bathrooms AI Dishwasher 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 P.1WDMTHE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: RAT pe'4y gg/Y cco c'o 1 WRITE DIRECTIONS(from _ aMocksville)TO PROPERTY: Tax Office PIN: # 7 / - - - �5-&' -5-% 1 1 /S8 Tt:, $D l - 1-4W t Property Address: Road Name f ,50PC,533 C r= A-- PO. 1 IeT ra /-70A = City/Zip AD✓A1.CE_ Al C a-700(e ' ' neteVL�=r p A/ 4U� 1 If in Subdivision provide information,as follows: 1 K Name: woe)Ids 1 / 1 1"me- Section• Lot #: ! 1 GCJ DA" 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 /�OU T—' to conduct all testing procedures as necessary to determine the site suitability. DATE 6 �• 7 SIGNATURE Revised DCHD(06-96) YOU AIAJ USE THE BACK OF THIS FOMf FOR DRAWING YOUR SITE PLAN. V ���� ----- / / ol d SIDNEY F. HOOTS / D.B. 175 Pg. 507 Na.. / N 33.47'22' ------ - / '�- E 231.61 ' �• ��--- 'a .-_� / �t Q�GI r---_.tQT #e -4. HOOTSro \ Or-`I'2y-/ /` 0 75 P9. 504 \. LO ' 7/ �,�� �/ 111 i i / � `/ // ( T '�' \� t \\ /AG9 }� p��� N I0. 1i53•I \t i 11 tl tt1 _� -� _ '� vpJ"'/\yy\ r\ ;i'J " I!6 9Lvo ,y 14 9� \ f�2 / \� 1 \ \i I �J /- q/ i l r / / ' ' j r I 1S6 i l \ # , , I ice; � \\ \� \� LOT 5/ r J \LmT\i�ls�` 1 r i GS ------- / r �� �` �i / i �•\+. t -��l i' 4/ i 1 / / i% / �/ 7 l I I GS I W els //���q{ LO //'( `\ \� ` � , \ / tl ��\ - �DYi, i i /�0 'yy, ,' / I a I tl o N PI . / I I NSI / ! . . ' / r LOT 2 ' ' a `" t LOT 01 LOTf17 ^/� rs� i / ,, / / �\ / / , \ �\ --1 150 -- -- 150 1_ SIGHT / - -LOT .� ---, BARO � ��� ,' �,.',d�• / ;/ ;//� l l (' � T/��j3-1-----� ,=__�/ / I / 1 � \ `� \� • r (/LOT,lf1 / / / �/ f i ' I I r /. _ _ I LOT\,XOT ho \ 9 I I LOT Ch1 �n i c�•r \ �ii�1 �N I a I r N t I nl �r t\\` tt I ' I / I \� `�` �--•-----� `\ tt I I I r � �� /i t6T #23/ ! �\ \ ��� / /�� / i 11 I I \\t 1' I 1 I r I r / LOT #I C) , I r / , ) t \ t , r / / 120 I i I ►+� � -LOT, 2� EOT #2 �` !/ ' /� �� i/�1/ '� I ( i // / t\ \ \` It \` —J ` 130 , I 140 LZJi` 2 rs / / . / / 1 � /! / , /,�J• 13s , 504 ,' /i -_o _ ' 6.71-_� NOTES ' HEAL COUNTY STANDARDS. 2. ROADS ARE TO BE BUILT T.