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592 Pine Ridge RdAUTHQRIZATION NO: .� ;� � UA COUNTY HEALTH DEPARTMENT , Environmental Health Section PROPERTY INFORMATION Permittee's P.O. Box 848 Name: /..� !�'� Mocksville, NC 27028 Subdivision Name: / Phone # 336-751-8760 Directions to property: Section: AUTHORIZATION FOR WASTEWATER Tax Office PIN:#_ ' SYSTEM CONSTRUCTION . Lot: Road Name: Zip: *NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building- Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ,.1 ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENAL HEALTHS'hECIALIST DATE ISSUED jar DAVIE COUNTY HEALTH DEPARTMENT - IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Permittee's Name:y`'s Subdivision Name: "Directions to property: '� %�-� fr` Section: Lot: IMPROVEMENT PERMIT Tax Office PIN:# Road Name: Zip: **NOTE** This Improvement Permit DOES NOT authorize the construction or installation 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) ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE ,' ;f' , • ; u,.. PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE _ # BEDROOMS # BATHS #OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPEE( # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY_ DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE " " SYSTEM SPECIFICATIONS: TANK SIZE �� GAL. PUMP TANK GAL. TRENCH WIDTH �b ROCK DEPTH � LINEAR FT. /'e) OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVE NT PERMIT LAJOU'1"APPROVED EFFLUENT FILTER* *RISE1i(S) IF 6" 13EL041 FINISIiED GRADE V 7WI) (4411tO p0,71� 4K c "CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS47W634-M0. (335)751-0760 I OPERATION PERMIT SYSTEM INSTALLED BY: Rs-� �)qw�d AUTHORIZATION NO. OPERATION PERMIT BY: /Ga�i� DATE: +tJ "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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. DCHD 05/96 (Revised) ..Y • D C APPMIKTIJi TE EVALUATION/IMPROVEMENT PERMIT & ATC e County Health Department ironmental Health SectionMEWzHEA5x 848/210 Hospital Street BVI DA ocksville, NC 27028 DRVIE COl1N1Y (336) 751-8760 33G sl- 8786 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. �� 1 . Name to be Billed LxrLJ% r 6 Iti�(� G /V e C n t Person J(�yl / Mailing Address 7 - / O me Phone l (� o City/State/ZIP JUS 6CJ6L); LbA G � �wCQ Business Phone �' / 7 b o (i1� Qt ' -7Y- !^7 2. Name on Permit/ATC if Different than AboveGC Mailing Address o. l/ O 5-7 7 3. Application For: ❑ Site Evaluation Improvement Permit ATC ❑ Both 4. System to Service: X.House❑ Mobile Home ❑ Business' ❑ Industry ❑ Other 5. If Residence: # People _y ! # Bedrooms 2 # Bathrooms &YDishwasher ❑ Garbage Disposal EI Washing Machine ❑ Basement/Plumbing H Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: X County/C:Lty ❑ Well ❑ Community 8. Do you anticipate additions or expansions^ of the facility this system is intended to serve? ❑ Yes ❑ No • -/Y- A If yes, what type? ,fir u i ev ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBM17YED by the client with THIS APPLICATION. Property Dimensions: l . kc," WRITE DIRECTIONS (from Mocksville) to PROPERTY - Tax Office PIN: # J��l�Li ,5-h767D (20 4 -pit-, e- l� �►e> Property Address: Road Name 6-7Z- 19;"F- City/Zip 9;"ECity/zip c%//U; Air- Lt S -'C o ri i �G ' If in a Subdivision provide information, as follows: Name: Section: Block: Lot: Date Property Flagged: b -f" � 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 to conduct all testing procedures as necessary to determine the site suitability. DATE 1 J g O SIGNATURE 4 ' THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (I clud4e all of the ollow g: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). r� �-'- '] / Site Revisit Charge /43 u- S .- 4 -- Revised DCHD (07/99) Sv'S Date(s): l Client Notification Date: EHS: Account No.3 Invoice No. , ;2-10 UZ/1b/ZUUL 1L:uu 1'AA Feb 18 02 12:58p UUZ/ UUJ Larry McDaniel Builders 3367511724 p•2 APPU ATION FOR SITE EVALUATION/IMPROVAtENT PERMIT & ATC Davie County Health Department � r7 Enlrilvnmental Health Section J/ I P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT .BE PROCESSED UNLESS ALL THE REQUIRED — INFORMATION IS PROVIDED. Refer tolthe INFORMATION BULLETIN for instructions. 1. Name to be Billed r 6 ��l fCC /N- D C n t Person -P A Hailing Address T - U 5 0t� Phone 151- 0 City/State/ZIP _ tK-JCS(//l/Fi AJ G �D Business Phone S^� Q f/1' Q� /! 7 LL 2. Name on Permit/ATC if Different than Above Giyky (;a 6� Hailing Address . �au 5 2 7 Ici o Asti ; e-, rJ 7 b T 3. Application For: 0 Site Evaluation Improvement Permit ATC 11 Both a. system to Service: XHouse 0 mobile Home 0 Business' 2D Industry Q Other 5. It Residence: ti People I Bedrooms ✓ r Bathrooms JIL "ishwasher U Garbage Disposal 11 Washing Machine LI Basement/Plumbing II Basement/No Plumbang 6. If Business/Industry/Other: Specify type # People # Sinks 1 Commodes # Showers # urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City 0 Well 11 Community e. Do you anticipate additions or expansions/ of the facility Ibis system is intended to serve? 0 Yes ❑ No ! / • -f(- A If yes, what type? ***IMPORTANT*** CLIENTS MUSTCOMPlerETIlL REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESU6Ml7TED by the client with THIS APPLICATION. Property ihmcilsions: q, 9,"c,, WRITE DIREC170NS (from Mocksville) to 1��1110I'ERTI': Tax Omec PIN: # 571K6 -5-47(v70 h e l� die, Property Address: Road Name 5-f2- Ane k,'441 City/Zip If in a Subdivision provide information, as follows: Name: Section: Block: Lot: Date Property Flagged: `�Y& D This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the inlurtnation submitted in this application is falsified or changed. 1, also, uudetwtand that l ant respo Bible for till charges lacurred fivunt 2oz. this application. 1, hereby, give consent to the Authorized Representative of the Davie County Health Department ^ , 11 ll to enter upon above described property located in Davie County and owned by �C LWJ UUJ/UUJ uZi10/ZuuZ lz:uu 1'r" —0— —0— —0-- -- -----Q----- ----- toconductall testing procedures as necessary to determine the site suitsmle DATGSIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (I ude all of t e allowing: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Revised DC11D (07!'99) 1i' Date(s): Client Notification Date: GHS: Account No. Invoice No. __ — �a I o yon ��ai� L68b 69LZ �`d9'6) i`dL'6) bl5b i