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190 Northbrook Dr Lot 19
•' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990003906 Tax PIN/EH#: 5820-32-9549 Billed To: Larry McDaniel Builders Subdivision Info: Northbrook Lot#19 Reference Name: Location/Address: 190 Northbrook Drive-27028 ATC Number: 4437 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 WASTE WATE ON TRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: 1 F4 accepted Systems may also'be use CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicatet a system d on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S.Cha ter A,Sect1 .1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY be taken as a g t t the sys em will function satisfactorily for any given period of time. l� tl u Septic System Installed By: / l �&�t Environmental Health Specialist's Signature: �`�� Date: DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 p� IMPROVEMENT/OPERATION PERMIT 11'� Account #: 990003906 Tax PIN/EH#: 5820-32-9549 Billed To: Larry McDaniel Builders Subdivision Info: Northbrook Lot# 19 Reference Name: Location/Address: 190 Northbrook Drive-27028 Proposed Facility: Residence Property Size: **N O" igql,"lh s�lmprovemeent/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 Garbage Disposal: ❑ Washing Machine:-El"- Basement w/Plumbing: ❑ Basement/No-'P'lumbing: ❑ Commercial Specification: Facility Type #People -#People/Shift #SSe-ats Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow(GPD) V Site: New. Repair❑ System Specifications: Tank Size,&�&GAL. Pump Tank GAL. Trench Width :ne- Rock Depth/b`�-Linear Ft.&9- � Other: air"4,f As stated in 15A NCAC 18A.1969(5) Required Site Modifications/Conditions: accepted Systems may also be used IMPROVEMENT/OPERATION PERMIT LAYOUT APPROVED EFFLUENT FILTER RISERS)IF 6"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.**** Ip' �r Environmental Health Specialist's Signature: Date: 4 / DCHD 05/99(Revised) .� 'APP OR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section 9X006 P.O. Box 848/210'Hospital Street t ��N 1 Mocksville,NC 27028 TM (336)751-8760/Fax (336)751-8786 IRONM���'N� Application i e Evaluation/Improvement Permit X Authorization To Construct(ATC) I�Both ***IMPORTANT"*THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed Contact Person MCDO)NJ Billing Address S Home Phone 09 City/State/ZIP 9 Business Phone C-(� Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION NOTE: A survey plat or site plan must accompany this application. (Permit is valid for 60 months with site plan,no expiration with complete 1at.) Street Address O( City i(�Q, Tax PIN#5CPA C� RO Icr�Dt ��(' Subdivision Name nOr+k Section/LotSection/Lot#19 Lot Size_ Directions To Site: Le r?3 &=. iaht 0 AlI'0 Date House/Facility Corners Flagged U S If the answer to any of the following questions is"yes",supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes; No Does the site contain jurisdictional wetlands? ❑Yeso Are there any easements or right-of-ways on the site? OYes-,NNO Is the site subject to approval by another public agency? ❑Yes o Will wastewater other than domestic sewage be generated? :]Yesowo IF RESIDENCE FILL OUT THE BOX BELOW #People a_ #Bedrooms b�� #Bathrooms Garden Tub/WhirlpoolYes ❑No Basement: ❑Yes ANo Basement Plumbing: ❑Yes ko, IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water.consumption) FOODSERVICE ONLY: #Seats - Type system requested: YConventional []Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: County/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes XNo If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes, or if the information submitted in this application is falsified or changed.' I understand that I am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules on the above described property located in Davie County and owned by c ---- - A Site Revisit Charge roper caner s or owner s legal representative signature b� t Date(s)-.- L02) ate(s):_L (3 _ Client Notification Date: Date 6EHS: Sign given ❑Yes ❑No Account# Revised 2/06 Invoice# �SZ/ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account M 990003906 Tax PIN/EH#: 5820-32-9549 Billed To: Larry McDaniel Builders Subdivision Info: Northbrook Lot# 19 Reference Name: Location/Address: 190 Northbrook Drive-27028 Proposed Facility: Residence Property Size: z, Z el 401- Date Evaluated: Water Supply:eO • On-Site Well Community Public Evaluation By: (`�� Auger Boring // Pit Cut FACTORSf. -- . 1 2 3 - _ 4_ 5 .., ._ . - 6 7 Landscape position Slope% HORIZON I DEPTH �! Texture group Consistence StructureCl/-- Mineralogy HORIZON 11 DEPTH f' Texture group Consistence Structure Mineralogy HORIZON III DEPTH - Texture group ,q: Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE P VVI SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S),PRESENT: REMARKS: Ste AijaAt a pAOX 1045- CQ LEGEND Landscape Position R-Ridge S-Shoulder L-Linear slope FS.-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope Texture S -Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE MQ1St VFR-Very friable FR-Friable FI Firm VFI-Very firm EFI-Extremely firm NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic 'P-Plastic VP-Very plastic Structure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogy 1:1,2:1,Mixed LYQt� Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface Saprolite-S(suitable),U(unsuitable) Soil wetness-Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification-S(suitable),PS(provisionally suitable),U(unsuitable) LTAR-Long-term acceptance rate-gal/day/ft2 I DCHD 05105(Revised) ■■■■■■■■■■■■■■■■raw■■■■■■�■■■■■■■■■■■■■■■■■�a■■■■■■■■■■■■■■■■■■■■■■ ■■■■MEN■■■■■■■■■11■■rAr1i:!HiMEN■■FR=nWE■■■■■■■wa■■ONO■►L■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■/S■■■■■/■■■■■iii■!7■■■■■�■■■■■■■■■■■■■►■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■pis■■■■■:!��■■■■■■■■■■■■rl■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■u■■■■■WY!YIE■■■■■■14"Mii■■■■■■■■■■■■■■■■■■■■►\e■■■■■■■ ■■■■■■■■■■■■■■■■s■■■■►ivy■■■■■■■i�■■■■■■■■■■■■■■■■■■■■■■■■■�s■e■■■■ ■t■■■■■■■■■■►_ill■■■■E:ViI�■■■■■■■■■■■■■■■■■■■■■■■■�■■■■■■■■■■■■■`!■■■ ■■■■■■■■■■■OUNRI■■■■■■■11■■■■■■■■MEN■■■■■■■■■■■■■■■■■■■■■■■■rid\■■■ EMEMEMiiiiC■p---:mmQrA MEMMEM MEMNONEMEMEMl,AMMEMEMMEMNON i ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ JUN-19-2006 07:39 AM LARRY.MCDANIEL.RUILDERS. 3367511724 P..01 APPLICNIIUN t'UKbI IL• r-V1%I..UIt&L JrvtltVII►w r&,r.aa+a.a s Davie County Health Department . ;., Environmental Wealth Section P.O.But 848/210 Hospital Street D �J Mocksville,NC 27028 U (336)751-8760/Fax(336)751-8780 t A, Application For: Nsite F..valuatioNlmprovement Permit Jia Authorization'I'o Construct(ATC) loth v�/y 9 ?W6 *•'IMPORT;lN7"*•THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF TIIE REQUIRED �+/UQ MORMAVON IS PROVIDED. Ret"to the INFORMATION IJULLETIN for instructions. `I rYi � ��t H�(� APPLICANT INFORMATION _ wy Name to be Billed 1TMt t L l5 ,_Contact Person Billing Address -7r _ Home Phone City/State/Zli' O i LU _ZL_ '_ Business Phone_-1�z I:9Qa Nacre on Pc'rmit/ATC if Different than Above_ Mailing Address City/State/Zip PROPERTY INFORMATION NOTE: A survey plat or site pion must accompany this application. (Permit is valid for 60 months with site plan,tto expiration with complete lat.) Street Address �4© � _, _ City, plat.) PIN#,s Subdivision Name�l atiC -_Section2ot _ Lot Siu_ Directions To Site: Date House/Facility Comers Flagged E R If the answer to any of the following questions is"yes",supporting documentation must be attached. Are there any existing wastewater systen onthe site'? ,1.1Yes—WNo. Does the site contain jurisdictional wetlands? rJyes n Arc thete any easements or right-of-ways on the site? !Yes o Is the site subject to approval by another public agency'? nyes o Will wastewater other than domestic sewage begenerated? 13Yes v IF RESIDENCE FILL OUT THE BOX BELOW #Pcople #Bedrooms •�-r_ #Aathroomg. GardenTuhlWhirlpoo1. (Yes I-IN I Basement:i"lYes� . n Basement FlYes NNO IF NON-RESIDENCE FILL OUT THE BOX BELOW Type oFacilityBusiness _ _ 'Total Square Footage of Building,____,— �,_#People #Stf inks:_ #Commodcs___ ^0 Showers —_ #Urinals Estimated Water Usage(gallons per day)— (Attach documentation of similar facility water consumption) I FOODSERV ICE ONLY: #Scats_ __ _ Type system requested:xt7Qnventional !!Accepted C_Innovative !]Alternative 110ther Water Supply Type:IYCounty/City Water is New Well OF..xisting Well 1':Community.Well Do you anticipate additions or expansions of the facility this system is intended to serve?!I Yes KNo Ifyes,what type? This is to cmt*tharthe-info!'ma lirovided ortthis application.is true and correet.to-the.best.of my knowledge..'I understand that any permit(s)or ATC(s)issued hereatler are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application it falsified or changed. I undertrand that tam responsible.for all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to detertnine compliance with applicable laws and rules on the above described property located in Davin Canty and owned by-_— _..--- ` _. Site Revisit Charge roper, wc{{r s�� r a ner's egat reproseutative xignaturc Gate(a);___ •_��t 3.l.,J.�___ Client No[iilcation Data:"� ,_—__ Dstc EHS:_.�___ Sign given LYen UNo Account 1i Revised 2106- Invoice 11 `__ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME DATE EVALUATED ADDRESS PROPERTY SIZE SS -X 10C 1 PROPOSED FACIILTY cs\) . LOCATION OF SITE Water Supply: On-Site Well _ Community Public Evaluation By:C.t,�- Auger Boring Pity Cut FACTORS 1 2 3 4 Landscape position Slope Z HORIZON I DEPTH Texture group " I- Consistence V-1 StructureMineralo HORIZON II DEPTHTexture rou Consistence h 1. Structure k Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS S RESTRICTIVE HORIZON — SAPROLITE ^ CLASSIFICATION LONG-TERM ACCEPTANCE RATE p SITE CLASSIFICATION: EVALUATED BY: LONG-TERM ACCEPTANCE RATE: �� OTHER(S) PRESENT: �D Q REMARKS: �� 11� , �- LEGEND Landscape Position R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope Texture S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt SICL-Silty :lay loam, SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-Vl--.-y friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm Wet NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic Structure 3C--Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogy 1:1, 2:1, Mixed Notes horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) Soil wetness - Inches from land surface to free water' or inches from land surface to soil colors with chroma 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD(01-901 1 No OEM ■■■MEMO■11■■■■■■■■■■■■■■■■■■■■■■■ N■■■■■■/■■■■.■■■ ■■.■■■■■■■■.■■ ■■■■■■■■.1■■■.■■■■■■.■■■.■■■■■■■■ ■■■■■■■■■■.■■■■■■S■■■■■■■■■■■■■■ OSOOOOSO OOOOOOOMEMEMEMEMM■OSSOOO.00OOSOOO■■OOOOO ■■■■■■■■■■■■■■.■■■■■■■■■.■■■■■■■■■■■.■MMM�I.MMMSS■O OME�S■■■■■n�i■■ ■■■■■■■.■��■■■■■■■■■■■■.■■■■■■.■■■.■■■■■■ ■■■ ■ ■.■■■■■■■c�■■■■■■■s■■■■■■■■■■■■■■■■.■■■■■■■.■■■.■■ ■■M■■M■■M■■■■■ON ■■■■■■■■■■■■.■■■■■■■■■■■■■■■■■■.■■■■■■■■.■■■■■■SMS■■■■■■.■■■MEMO■!■ SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSOOO■iiiiiiiiuO.00SSS=O=SSSSS11S SSSSSSSSSSSSSSSSSSiS ■■■■■■■E■E.■■Ea■■■Es.uEMM■■M■■■■M■u■■■■■■■■■OOS■■M■S.■E■■■■■■Wi■S ................■■■■■EH■■■■E..■M.■■■■■■■■E■■■■■ SMSS.■.5..... 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OS �S ■■■ U■■■■■S H■■ N■■M■■■■M■M■■■■■ u ■■■■■■■■■■■■E ■■ ■■■■■■■■■■■■■■■■■■■■OMMM■■■■■■■■■■■■■M■■AM■■■■■■■■E■■■■■■■■■■■■■■■ ■.■■■■■■■■■■■■■■■■■■EOMMMM■■■■■■■■■■■■■/I■■■10■■■■■■■HM■■■M■■■■■■■■ ■■■■■■■■■■■■■■■MMM■■■\\E■■■■S■■■■■■■■■■■lI■■■■■■■■■■■■■■■■■■■.■■■■■■ MOSSSSSSSSSHSSSSSSSSiwMSSS■SSSSM OSS�I�SSSSMMSSMOSSM■OSSSSSEMMUMSIn S■■■■■■■■■■■■■■■■■■■■.\\■■■EMM■■ ■■■E.r/■■MM■MMOMMMEMEMEM■MOMMEME■ ■E■MEM■MMMEMMMMMEMEMEMMEM■■■■u■M■MM Is ■■■■MMMMMMMMMMMMMMM■M■M■ APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT&ATC . Davie County Health Department Environmental Health Section P.O. Box 848 Mocksville,NC 27028 (704) 634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed /�^ Contact Person D — T30 0 Mailing Address `7/97 �G`���2 Home Phone City/State/Zip �0 �✓�.✓s�ti/.SAG /[/G'�7 � Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: [ ]Site Evaluation [L]/Improvement Permit&ATC [ ]Both 4. System to Serve: [t.]�House [ ]Mobile Home [ ]Business [ ]Industry [ ]Other 5. If Residence: #People_ #Bedrooms ? #Bathrooms [✓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: [00unty/City [ ]Well [ ]Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes [-I/No If yes,what type? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED:***IMPORTANT OF THE PROPERTY MUST BE t SUBMITTED WITH THIS APPLICATION. Property Dimensions. 5� ���� WRITE DHtE TIONS(from Mocksville)TO PROPERTY: Tax Office PIN: # Property Address: Road Dame Zr CQ ��- City/Zip o� ll .t10-"Z If in Subdivision provide information,as follows: Name: Q � Section: Lot#• 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. 1, 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 to conduct all testing pr res as necessary to determine the site suitability. DATE /6' q7 SIGNATURE Revised DCHD(06-96) � THZS AREA MAY $E USED FOR DRAIVINC YOUR SITE PLAN: F �f �a JSQ S6 t APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM Q U U Davie County Health Department nc Environmental Health Section SEP 1 8 XM P. O. Box 665 Mocksville, NC 27028 ENVIRONMENTAL DAVIE COU 1. Application/Permit Requested By Mailing Address Home Phone !?9,9#71 7 Business Phone } r 2. Name on Permit if Different than Above 3. Applidation/Permit for: P/General Evaluation ❑ Septic Tank Installation 4. System to Serve: (P/House ❑ Mobile Home ❑ Place of Public Assembly } i. ❑ Business ❑ In Other ❑ Unknown 9 f 5. If house, mobile home: Subdivision � )0 le vRaoSection Lot# ❑ Basement/Plumbing No.of People ❑ Basement/No Plumbing No. of Bedrooms ❑ Washing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type i No. of People Served No. of Sinks No.of Commodes No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: B-Public T. ❑ Private ❑ Community 8. Property Dimensions ( ,,f-,c6„�t�lc, G G�t'� Sewage Disposal Contractor 7 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No If yes, what type? *NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. f p i Directions to Property: 1 , C'✓Yti (aG� � V 11L`�"''' G��, 010 This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this application. DAT SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 1. I OWN the property. ❑ 2. 1 DO NOT OWN the property. If you checked Box#2, the rest of this form MUST be completed by the owner or a person authorized by the owner: 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 to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD(12-90) i �I I - I I I . I - I . I . � -1 I I , ., _ , , I �_ _ , I I I I . , � . , , , � I I I I I � I , .� I . '. - I I " , . . "I. I ,-", � . 11 I . �. � : � I -1 . 1-1 � I I I . 11 - , I -1, � � �- I . I I I I � , . . � � . , : , _ -1 - , - - , I I I , -- . , , - " . . I I � I - . , I .." 11 I ,- . 1. .1. � I , - I ._ �_ -�.��i,l�,.,.--,�-, ;;:.� , ' ' - - , , �,�,.-- . , � . 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I .1 I I � ; � __ 1- 1�--�-----.---.----- -,� ----------- � ___ ____ ______ __ __- ______ __ - -____ _____ I-------- I - - ____ - __ - I _ __ Davie County Health Department EnvironmentalHealth Section P.O.Box 848/210 Hospital Street Mocksville NC 27028 (336)751-8760/Fax(336) 751-8786 - June 23, 2006 Mr. Larry McDaniel P.O.Box 577 Mocksville,NC 27028 Re: 190 Northbrook Drive Tax Pin#: 5820329549 Dear Mr. McDaniel, As requested, a representative from this office visited the above site June 23, 2006 to perform a site evaluation. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed,the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. 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 or the intended use change. Improvement Permit System To Serve: Wastewater Design Flow:� � System Type: ❑Conventional ccepted ❑Innovative ❑Alternative []Other System Location: �lii � Valid: 05 ears ❑No Expiration Site Modifications/Permit Conditions: r Environmental th Specialist Date ps-i.p.letter 2/06