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228 Danner Road Lot 44 _ DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 989900216 Tax PIN/EH#: 5820-65-0632 Billed To: Paul Willard Subdivision Info: Pepperstone Lot#44 Reference Name: Location/Address: Danner Road-27028 Proposed Facility Residence Property Size: see map ATC Number: 4190 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 CONSTR CTI IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date:or f r� 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. after 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY be taken as a g ar tee that the system will function satisfactorily for any given period of time. C� Lr Septic System Installed By: 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 IMPROVEMENT/OPERATION PERMIT Account M 989900216 Tax PIN/EH#: 5820-65-0632 Billed To: Paul Willard Subdivision Info: Pepperstone Lot#44 Reference Name: Location/Address: Danner Road-27028 Proposed Facility Residence Property Size: see map ATC Number: 4190 **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 I 1 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:0'0' 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❑ Repair❑ System Specifications: Tank Size A00 GAL. Pump Tank GAL. Trench Width_\a Rock Depth ]Linear Ft. Other: OCCepted Systems may also be use 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 H Ith 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 install io . Telephone#is(336)751-8760.**** 1 Environmental Health Specialist's Signature: Date: qlo'A�s DCHD 05/99(Revised) .-r . APPLICATION FOR SITE EVALUATION/IhIPROVEMENT PERMIT&ATC Davie County Health Department D 0 Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 SEP 2 2005 ***IFtPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLES ALL INFOR2iATION IS PROVIDED//. Refer teof the INFOMIATION BULLETI for ins r 1. Name to be Billed �(Zt.(SL� ��pl� /I Contact Person Mailing Address 1223 ( -f fr7t,CECJ1� �/rJ, Ilome Phone `�31P City/State/ZIP _m� 4(J� r� / /C oy/�OSO Business Phone L�` 5 ' 1p9 3 2. Name on Permit/ATC if Different than Above Mailing Address ity/State/Zip 3. Application For: ❑ Site Evaluation Improvement Permit/ATC 0"Both 4. System to service: 1'Iiouse. ❑ 14obile Home ❑ usiness ❑ Industry ❑ Other 5. Typo system requested: ❑ Conventional ❑ conventional modified ❑ innovative t'aCCepted 6. If Residence: 0 People # Bedrooms 9 Bathrooms L,ZDishwashor ❑Garbage Disposal `1JWashing Machine [ Basement/Plumbing [ basement/No Plumbing 7. If Business/Industry /Other: verify type t) People # Sinks Commodes t) Showers S Urinals tt Water Coolors IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) S. Typo of water supply: h County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes Ergo If yes,what type? ***I11lP0RT1iNT***CLIENTS111USTCOMPLETL•THE RL•QUIRED PROPERTY INFORMATION REQUESTED BELONV. Either a PLAT or SITE PLAN AMST BESUM TTED by the client with THIS APPLICATION. Property Ditticnsions: �� —"`�'� WRITE DIRECTIONS(from Mocim,111c)to PROPERTY:' Tax Office PIN: iE b /l/. Property Address: Road Namc i�� ¢� �-r.� A�ak± City/Zip If in a Subdil, ' t provide information,as follows: Name: J/ r / Section: Block: Lot: •"'T Date home corners flagged: ` s This is to certify that the information provided is correct to the best of my knowledge. I understand that any perulit(s) issued hereafter arc subject to-suspension or revocation,if the site plans or intended use change,or if file information submitted in utis application is ralsifled or changed. I,also,ituderstand that l ant responsible for all charges iucarrcil frogs this application. I,hereby,give consent to the Authorized Representative of the Davie County IIeallh Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE ��_� �/� SIGNATURE. TIIIS AREA MAY BE USED FOR DRAIVING YOUR SITE PLAN(Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge v Datc(s): C ^ Client Notificatiotl Date: EI-IS: � Sign given Account No. 0 CD Revised DCIID(05/03 Lrvoicc No. 5-o d lr sip -'- oU�� C['ic%on tha septa: Map Li C•Ij�3i. . Parcels= �= .;ZOMID C.;oasUot 2exaEar NaP �l tknw se'eQ Ims Faslo+ _ki ! Radus SearD(teary _._ Boundary caws Tra (�W "; r c�ly 3o n9 6ID51 j comaZor t M' Syl ` 7 91 r'Egli Flm V Flood Pane • i L d 4901 � �� E Flood toes (363) civ Parcels L_ 1631 r= stnod Diss _ Mati Syl .•. tIV �2Q C..�.._.�f f - - stabs ' f�7t vL � �._... zonif 8fZ4 �py�p - - 1 L 7ovnslips ft? 38LlaSl2 [ f •�rJ�t� b579r �1 7554 256'7 4534 *jag rN w' �'.YoisgAnl w S5� 54 w /r I 5 � -� �In ff` 7437o� t Rail Limes _ ( R F:USfNCKi¢ o r�, 0315 ;f 9337 1 0345 � 13c 4 � � ', Wiutb Syt COOy�. f cE f U CC M Parcel Data t✓ar:..l)J.n� w - o w ■n 0 0 ca 0 rn 0