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194 No Creek Rd
, � , � DAVIE COUNTY ENVIRONIVIENTAL HEALTH . P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)'751-876Q Fax#(336)751-8786 OPERATION PERMIT Account #: 990004203 Tax PIN/EH#: 5768-40-2773 Billed To: Gary Hawks Subdivision Info: ��9� Reference Name: Location/Address: No Creek Road-27028 Proposed Facility: Residence Property Size: 6.467 ATC Number: 4582 **NOTE�*The issuance of tlus Operation Pernut shall indicate the system described on the ATC has been installed in compliance with Article 11 of G.S. Chapter 130A, Sectinn.1900"Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactarily for any given period of dme. System Type:�� �S.T.Manufacturer 1�� Tank Date�'^�^��'Tank Size ��� _ Pump Tank Size �`-' . System Installed By: �`tiL l'� �-v��. E.H. S 'alist: �g �7 � 3��lZao� � Q�►� �.sz'� c-*'��.&� F��r �}�s�:, �1' �f . �2� �.- �S r �� ,[SJ a c � � � � �., �j � � 1) t� \1 � ^ � � � S� DCHD 11/06(Revised) , � �r•7C7 , , , nav�courrrY Errvn�orrn�rrrai.�ai,Tx �� • P.O.Box 848/210 Hospital Street Mocksville,rrc Z�oaB a�a3Co� (336)751-8760 Fax#(336)751-87�6 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTYiUCTION Account #: 990004203 Tax PIN/EH #: 5768-40-2773 Billed To: Gary Hawks Subdivision Info: Reference Name: Location/Address: No Creek Road-27028 .Proposed Facility: Residence Property Size: 6.467 ATC Number: 4582 **NOTE**This Authorizadon to Construct(ATC)MUST HE ISSUED by the Davie County Environmental Health Section prior to issuance of any building pernut(s),(in complianee with Article 11 of G.S. Chapter 130A Wastewater Systems, Section.1900 Sewage Treahnent and Disposal Systems). THIS AVTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD FIVE YEARS. This ATC is subject to revocaUon if site plans,plat or the intended use change. Residential Specification:Building Type_����#People 2- #Bedrooms 3 #Baths 2- ,�''— Basement w/Plumbing:T Basement/No Plumbing� Commercial Specificatian:Facility Type #People #People/Shift #Seats LoL Size.�'��S_Type Water Suppl�'�pesign Wastewater Flow(GPD}�t� Site:New✓12epair n System Specifications:Tank Size1L"C�� GAL.Pump Tank�GAL.Trench Width� Trench Depth���^�'� Rock Depth ��'� Linear Ft.�j' n . As �t�te€� i� �.5A NCAC 1�A.19G�(5� Other: 3 �SrW��/Dn� �iYL� �ccepted Systc;ms raiay also k�e use �' Required Site Modifications/Conditions: �nk�TALL � ��ro'�'� ��=(�� ��91�1_,S Contact thc Davie County Environmental Health Section for f al inspection of this system between 8:30–9:30a. on the da of installation. Tele hone# 33�'751-8760. � �o � , til,��: g�� �a 'I�-lcA ��'�Z� � � � _ � n � � � � � � � ,�,� 1� `}, M ��-� 1 � lno" -.� .--- � �rZ��tc �— �rn-�� � � �U4k-'J' to� �ct2 " � �(c(�� I ' Enviromm �tal Health Specialist Date: — �12�--(�,�.,� ��� DCHD 11/ (Revised) � JAfd,/04i 2007i'THU 11:02 Ah4 PENN ENGIt�1EERING FAX No. 336 777 1538 P, 002i003 Jan� 02 07, 10:37s davie:lcounty envhealth 336 751 8786 p.2 � � �n ��� � �\-� `� ' . � � �, APPLICA'tION F CE�VAL�IATION/IMPR�JVEIVIENT P�-;RMtT&ATC � JA�' _ � L�O� � avie County Envirunmental'liealth � P.O.Box 848/21Q Hospital Straet MockaviIIe,NC T70Z8 (336)751-8'f60/FAx(336)751-f�786 . . �NViRONiv1[�iT' hr�111H � App catio�,�i Sito�fvaluatio ent Pennit p'Aulho�ization To(:onsuuct(ATC) : (�9oth mn�" w Systom '.:R��p�ir to Exuling Syt�un 4Fxpancion/Modification of Cxisting System or Faciliry � ••'1MPORTAN7***THIS APPLICA'fI(?N GfNNOTBE PROCESSED UNll�SS Ax.L OF THE RBQUTASD INFORMATION 1S PROVIDLD. Rcfcr to the TAtFORIvfAT10N HULC,E'IIlV I'or instructions.' " APPLICANT INFORMATIQN Name to be Biited L�Q P�U�_T7�LW S Contar•t Person /.�f'ei'jf1 LC.. �-la evks Billing Address /Spp T�y, i / Ho»�e Phone 3310-•-78y-fpSOD City/Statc2II' _NG Zti�9 Busine:ss Phone_33fo-7Zlo- Z7 84 Name on PermidATC if DiJJ'erenl tUan Above .�/►x� Mailing Address cSoeivnQ. Cih'�State/Zip —�---. /� PROPER7'Y 1NFORMATION � "Date HouselF:uility Corners Fie� e� d��'[�`V / NO'I'E: A survey plat or xite plan trnr�t si�:ompany tllis appiicati�n. Tncludet�:�Site Plan flPlat(ro scale) (Pumit is alid fot 60 tnonths wita sile plan,no cpicati0p witb wmpkte plat) Owaa'aName r �P.�ren�Q� t�-�CZul�S PhoneNumbe���f��787-/cS00 Owner'sAddress_ / Q�pr.lcct L % c�]�ty Cit�IStatd'LipNL �7�-95� ' PropertyAddress D N ek."��ae� City �oc ✓il e .NC Z7D28 � LotSize (,.41,'7 racvPs �1'axP1NN 5 O Su6divisian Namc(iCapplicable)__ -=-' Sectioi�/Lot# Directioas To Site: ��_ U�(o�y�a.of-�.`�o � i � the swet t any folbwu�g quesGrnu is'yea",supporting doctunentatiim must bc ttached. . "' Aie qtere aqy e�ciating w�stawatu aystettl9 ort tbe site? []Ye61�10 Does the site conuin jurisdictionai wodands? OYa Fi!�o � Ate there any easemeats or ci�lit-�;f-ways oa lAe site7 OYes�io _ L+thc site sut;jeci to approvsl by uaofl►t(publit ageacy4 ❑Yes fi?�10 Will wastewatez other thaa domc::tie acwwnge be gmenced? UXes S�Vo ' IF L2k:SIDENCE FII.L OUT'T�IE'3�7t BELOW � #Peoplo aZ.. �l Bedroon:s ��_ #Bsthrooma,s? �.,d2. Garden TubfWhirlpool es UNo Basement:f]Yes�lo $ucmc�:t Piumbing: OYcs �(No ff NON-It�SIDENCE FTT,T.OtTf THE BOX BELOW Type of Facility/Husiness _, Total Squere Pootsge of Buildinp_. #People #Sinks N Commodes #Showers #Urinals Estimated Water Usage(gallans pbr d:y) (Attach doeumc:ntation oi similar taciliry w�eer consumpeion} FOODSERv10E ONLY: #Seats__,�,�� Typesystemtequeated: [�onventioaat JAccepted ❑[nnovative DAltcrnative OOcha WOter Supply Type:f�Cour�ty/Ciry Wata ❑New Weli OExisiing Well 0 Conimunity well Do you anticipate sdditiom oc expamio�of tha facility Ihis sysrem is intcnded l0 Serve7 0 Yes ,Y1.No • I[yea,wlut typc? , . This is to ceceify�Isat t1ro infocmution p�ovided on t�iis applleaGon is aue ond ca rrect to the best of my knowlcdge. T understsnd that any permil(s)or ATC(s)issued hemaftr:r�.re eubjecc to suspension or rovoeadon if the aite{e alteced,the inter�ded use ehenges,or if the iuformation submilted in this applitat[an is falsified o�ch�nged !here�y gr:�nt right of enoty.to Ihe Authorl2ed Itepresantetive of the Aavie Coanty Health Deperbtunttt�eonduct aeceuary i�pectiuns fo detGtmine cemplianee N ith�pplicabla(awa nrld tulcs. I undcrstsnd that I am respons�'blt for U�e;uoper identification and labeliog of�zoperty lines and,conicrs and lowting and flagging • or saking the housdfaciGry lncation,p�nposed wr,ll lotation and the location ol'sny oUxr amcnitics. /:1/(0 ni`I11.� (� S� Site Revisit Charga Propecty'owner a oro�nner'a kga)reprcae��tative signanue : Date(s): I�a�O�y CliontNoti[icationArte: _ � EHS: Date ' Sign givcn OXes ONo Account# �`� Revised 1 U06 I�tvoiee k •�Z JAN/04/2007ITHU 11 :02 AM PENN ENGINEERING FAX No. 336 777 1538 P. 003/003 1 • J � ' --�..... .__....._!-•---�._._.... � . � r ...'I.,._..�.._ ._.. .._._...--;...__.'-_._�:..�. ....... -- —. �.._ _ _._,�-- — — - �_._ � � �. . y ; � .—^.... 1 . � ..^ 1.__.1_.... . ` � . 1 ,,:.._,...�. ...... �..i.,_...I,,......t...._.� �..... • . _ i �. . 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■■■■■���■■��■��■■■����■■■■����■����■■��■■■����������■■■■■■■■�■��■■ ■�■��■■■■■���■���■�■��■�����■■�■��■�■��■�■��■■�■■■■■■■��■�■�■�■��■ ■■�■�■��■■■���■��■�����■■■��■��■����■■■■�■■■��■��������■■���■����■ ■����■■■�■■■■■��������������■�■■■■�������■�■�■■■■■��■■����■■■■���■ ■�■■■■■��■�����■■■�■���■■■����■��■��■■■■■■��■��������■��■■■������■ ■��■�■■■■■����■■■�■■��■��■���■�����■■�■■■�■■�■�■��■�■��■■�����■�■ ■■�■�■�■��■■■■��■�■��■��■���■■■■ ■����■��■�■■■■■■�■■■��■����■�■�■ ■■■■■■�■■��s■�����■���■����■■■■��■��■�■�����■���■■������■��■���■■■ ■■�■�■�■■��■���■■■■■�■�■��■������■�����■■■■■■■■■■■�■■■■�■�■■■■�■■■ ' � �� � Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 990004203 Tax PIN/EH #: 5768-40-2773 Billed To: Gary Hawks Subdivision Info: Address: 1500 Becky Hill Road Location/Address: No Creek Road-27028 City: Lexington Property Size: 6.467 Reference Name: Proposed Facility: Residence **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. Permit Type: , ew ❑Repair ❑Expansion Pernut Valid for: Years ❑No Expiration Residential Specifications: #Bedrooms � #Bathrooms��#People 2 Basement0 Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):� Type of Water Supply:,�'C�ounty/City OWell ❑Community Well Site Modifications/Pernut Conditions: S stem T e LTAR Initial ty.J�1, t�. Re air pNaL �•Z Site Plan Nc' ��r�,�� �� � �� � � 1� � -�`,,�� �1�17 I/aL �.,y� I I ��alQ. ,�,Q,2,/,� I � t v � � , Environmental Health Specialist �`��t'�� ��j_ {,� ��:D te r i.p.11-06 / � �