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225 Oakdale Circle Lot 3 • �' HEALTH DEPARTMENT RELEASE For Office Use Only *CDP File Number 121485- 1 d s o Davie County Health Department L5-000-00-075 } 210 Hospital Street County ID Number: P.O. Box 848 Evaluat C Mocksville NC 27028 Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID , 0 5 / 1 4 / a 1. 8 UNTIL: Applicant: Tommy Harris Prop rty Owner: Kimberly and Greg Mattingly Address: 277 Peasant Acre Drive Add ss: 225 Oakdale Circle City: Mocksville City: Mocksville State[Zip: NC 27028 StatefLip: 27-0 Phone#: (336) 909-4027 Phone#: Property Location&Site Information Ad ess225 Oakdale Circ Subdivision: Phase: :�59 Ro NC 27028 0202E AMILY Township: 'Structure: Directions #of Bedrooms: #of People: Hwy 601 South,Left on to Hwy 801,Oakdale on right 'Water Supply: WA Type of Business: Basement: F]Yes n No Total sq.Footage: No.Of Employees: 'Proposed Improvement: Poo120x40 'Release Conditions maintain a 15'setback from septic tank and drainlines. This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps.Signature Required? Oyes ONO Applicant/Legal Reps.Signature: *Date: *Issued By: 2244-Daywalt,Andrew A *Date of Issue:. 0 5 / 1 4 2 0 1 3 Authorized State Agent: **Site Plan/Drawing attached.** Tots lTlme:(HH:MM) 0 1 Hours 0 0 Minutes ®Hand Drawing OlmportDrawing Davie County Health Department 9 18 jfi Environmental Health Section - ,.�:�,� . P.O. Box 848 1 210 Hospital Street W®, O U Courier# : 09-40-06 Mocksville, NC 27028 Phone:(336)-753-6780 Fax:(336)-751-8786 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection Name: 0111 Zr/1(L tz S Phone Number 9 0 �— /—(�2 7_(Home) Mailing Address: ;27 7 I e'eef/✓v Ira (Work) Email Detailed Directions To Site: 6 �o �� All Ly-oOo-�-o7S Property Address: a C �� bv�FG�5/ole-5 Please Fill In The Following Information About The EXISTING Facility: Prop�r� sio Name System Installed Under: Type Of Facility: �0 US Date System Installed(MondMate/Year): Q Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? Ye No If Yes,For How Long? Any.Known Problems? Yes No If Yes,Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: �� a )( Number Of Bedrooms: Number of People Requested By: Date Requested: �EZ&11,3 (Signature— For Environmental Health Office Use Only (Approved Disapproved minents. Environmental Health Specialist Date: *The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee (extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # ��2� Amount:$ 100,C) Date: Paid By: Received By: Account#: Invoice#: c�� l a _ ---L1-oo OAKDALE CIR 153 100 10 '" 10p-- 100 1200 225 ; r - --• L200 PP ' p i -- 00 150 100 100 00 150 N I( X133: N a N x'147 X103 10.0:... t tT o °jF All data is provided as is without warranty or guarantee of any kind either expressed or implied Including but not limited to the Implied warranties of merchantability or fitness for a particular use.All users of Davie County's GIS website shall hold harmless the County of Davie,North Carolina,Its agents,consultants,contractors or employees from any and all claims or causes of action due to or arising out of Pri nted:May 06, 2013 1 the use or inability to use the GIS data provided by this website. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Qct P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 "" 3 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002683 Tax PIN/EH#: 5746-83-7931 Billed To: Tammy Stewart Subdivision Info: Oakdale Lot#��3 Reference Name: Location/Address: Oakdale Circle-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3432 **NOTE** This Improvement/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:17 Garbage Disposal: ❑ Washing Machine:12 Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply L d Design Wastewater Flow(GPD) Site: New.12K"'Repair❑ System Specifications: Tank Size�_LeGAL. Pump Tank GAL. Trench Width Rock Depth Linear Ft.�0o Other: w�� Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)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.**** Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) r i DAVIE COUNTY HEALTH DEPARTMENT '•� Environmental Health Section Q� • P.O.Boa 848/210 Hospital Street /• Mocksville,NC 27028 _ 3 (336)751-8760 IMPROVEMENT/OPERATION PERMIT 2OG�� k;mbzrly v-� � �N l - Clr e . Account #: 990002683 Tax PIN/EH#: 5746-83-7931 Billed To: -Stawar4- Subdivision Info: Oakdale Lot#p3 Reference Name: Location/Address: Oakdale Circle-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3432 **NOTE** This Improvement/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 �9 #People —2' #Bedrooms_. #Baths Dishwasher: Garbage Disposal: ❑ Washing Machine:la Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #S\\eats Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow(GPD), U Site: New)2K*Repair❑ System Specifications: Tank Size%2eGAL. Pump Tank GAL. Trench Width Rock Depth Linear Ft.6�00' Other: 'e1,014' ya,jut —4q Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)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.**** l� Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised)