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170 Cecil Ln Lot 2 �Permi we's DAVIE COUNTY HEALTH DEPARTMENT Name: IaN�� � `+�^ Environmental Health Section PROPERTY INFORMATION . _---. P.O. Box 848 Directions to-property: `�t� Mocksville,NC 27028 Subdivision Name: -7 ,�( G� j 1O1VIAA Phone#:336-751-8760 Section: Lot: �- ��``� AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION - J! ,,�`` - AUTHORIZATION NO: 002767 A Road Name: 17p 0--�1 L gip:L.,702ee **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 Articl1 of G.S.ChapWr 130A•Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRON E- L A PE ";AL DATE 1 SUED RESIDENTIAL SPECIFICATION:BUILDING TYPE rJDQS&#BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE ' #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No �V LOT SIZE TYPE WATER SUPPLY ELI- DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZEt�GAL. PUMP TANK GAL. TRENCH WIDTH ` ROCK DEPTH �'� LINEAR FT. OTHER Aac(.f I� 2-51 Ot--D cpa4 6 JIChi t n � REQUIRED SITE MODIFICATIONS/CONDITIONS: �l'• sK' ✓ Ql't ��i�L'l. IMPROVEMENT PERMIT LAYOUT Njio�� .�� � c,� vw y ,eco..• r � '' FX15I1rJa . I I � 1 C X I S'I-I,%J 16-1210-12 7 f3La_q 1rJA IrJG7 LVL 'K o�J S yS�c. FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760. OPERATION PERMIT 3 O�O(p It 01 SYSTEM INSTALLED BY:i 111A,434 A& ��Ad � D N�It-et#1 Ca y4� �� 3. C��) - �LCw p tti�i 9 / O • ���n r r< AUTHORIZATION NO. OPERATION PERMIT BY: DATE: **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 FUUN/CTION/SATISFACTORILY FOR ANY GIVEN PERIOD OF TIMEE.. oclln 02/02(Revised) dd �f' w "V(�d;0� —`"� emu[tee's, ,r' DAVIE COUNTY HEALTH DEPARTMENT e: 1rVQ !`�� �yE- Environmental Health Section PROPERTY INFORMATION P.O.Box 848 Directions-t p perty:{ aU)�1 �I Q` Mocksville,NC 27028 Subdivision Name: 1 � � � ' J Phone#:336-751-8760 - . � AUTHORIZATION FOR Section: Lot: /v4\/t/�. CAL L•A/ WASTEWATER Tax Office PIN:# - SYSTEM CONSTRUCTION AUTHORIZATION NO: 002767 A Road Name: 1-7c) t"i'`�-1 "dip:"lyze,') **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-1 I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) 1 ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION 1/0? IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONBIIENT.L AL I SPE6ALSt DATE 1 SUED RESIDENTIAL SPECIFICATION:BUILDING TYPE OW51r#BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT' #SEATS INDUSTRIAL WASTE:Yes /orNo LOT SIZE TYPE WATER SUPPLY 1NCLl, DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE=— GAL. PUMP TANK GAL. TRENCH WIDTH ` ROCK DEPTH LINEAR FT. OTHER ITL�� r.��o t=t1���I1 S7 SILAti REQUIRED SITE MODIFICATIONS/CONDITIONS: I E s t �5 a F'I''!L7 IMPROVEMENT PERMIT LAYOUT 1 ����/ enAv",Of t� c,T1,3 -TI n _1 > I i _ Gw 5' Nka -t' AP&,,,14�, lit: FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760. OPERATION PERMIT .3 O—6(j t' n t da�C Q )\y r SYSTEM INSTALLS pY: 1)600 yfl �jt� 3 ye r AUTHORIZATION NO. OPERATION PERMIT BY: 4 DATE: ■$THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 1 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 - SYSTEMWILL FUNCTIONSDATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.. Uajo (" �' DCHD 02/02(revised) FzV(/ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION 70 C-ce,i t G� 1tk6Ck'V41( NC Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 3 4 5 6 . 7, Landscape position L L L Slope% HORIZON I DEPTH p - to 0- Texture groupG Consistence Structure / Mineralogy HORIZON II DEPTH -c{ Texture group Consistence 1� S Structure Mineralogy S - HORIZON III DEPTH Texture I group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence -Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON �{ SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE 0 44 Z SITE CLASSIFICATION: Pr d J.5 t /w 5 I r EVALUATION BY: LONG-TERM ACCEPTANCE RATE: G• G OTHER(S)PRESENT: REMARKS: .2 C Gt-Dl`/Zln�b /rj (� !` 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 Moist 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 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 05105(Revised) ' .'.,:...'..•� .µ-`i.a*-..".:.:.::,.`mo'*i*"'a=7�x+,,a}f.�M�...a.a.^s..."4',„.!',....a•°%*..�»;�.T�"�'"��?t�. „.r..±.a'. .,��.,'�'.�„��yy',a'„,�T;,s++,..";.,.,»,_.�..�:s«ay.r::4..�.X.,�r.'"k.,,,a"3.p.'hag ye.yt_�.»:.:::>.>"��'+a.�y.'r"X«`.�."+«..�<.�,.fi�'r'„px.r*..�_";EE,'���F�'”rr."°xa.`�,p�,.}�a��^«+«'":'+•uc.r�'"�."i'«'ry",`ay{r s!-F.a a�,a..'::.-:,.:;,;a,p�•'.c��a`.;�Y"T.7L-.�.a..d.x�Y.+�."re+•>.d:.."`"^n",,:#.,rP�krwit�`'tr"T,wwSt,»v.•.i.',M,'-,M.t'.ar.a''.d�#�,'.n�`<",4a«':M,�,,_v. �tir�i,ak.-v�.�+..«c.�_in.rt'':.,',T^.<.„..T#u�r=^�vi.�""`.��a.''.s!T...�.�,:...3,s`�#a.>.,�,.`�._;$cv!,.;e i ,.r�."wu,.., �,..,. `«A.c�-,;�...'.„e..i''§,`,.i s�: . §,°'.','«'%�i-'' : �...,��"�"`,°.».`",.,.,�.#,".:"»:..,:,c':•a,.._.,�aa.='�4v.e r;,Xg'=:��_�; �'��.�,�;�_v,ea-,s..>R.'�..".�,�,,2,.#:aq 4°m.�t4Q,a z..r,,:.gi�,�,�v,,,#g'��k«..:a.::ms}.-��''s['x..,:.�'az',aa..g�«aa"»•F�r.,.�ai,�.a',•'.s.im;7 two ME- In w NA .4.»' r. 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Sr r9 y �� T W� �. �t °{.��"��� ,y d r' ti i��"'•.�! ` r # r �own," f r • ,: � ♦, ,y 'a.5 w'.. - °a; t� t$,,.`�,.�w;�i .ir �:r�++ :=ya`tr '_"[i+4.r-�'�..�`X` � ,.�,» 717V a F 5� r�' a. x r' 1 • S f *v' vq` �5 ;R.� } �T. y .-: sa ,i .; .. � ;"'� va.,l�rq"5,�,�7^�vs..y��� • y'Y4�.a,�"� '�+ M "� g �Xa Mr�"�*� .#°S�����J 5.t`� 4�. : }=X t ;°' '�•�4i �'"i pr �t�a�re a .r,� rF�.:rN r` 's. 3' hd'Gt'# , + t`. r r �, �. � .��r � �'. � #.. ���: ''� :" M T�#j���r`� * :.>t, ;�rt e .r i. � �. �'•ti;.�r�«r r-�tui�8'k: < ' p ' ei 'T ,4��M.!s'�►. '+t'�.rr�•�.,�."�»,�.'„�,d'�L..�^,iC�•,T�q,�'*' ,,��,..'",M' �arr. ?�°i�11 # y#' � ,"a: .'�} �t rllif•11�• i s �a� r�r�'�y*i:aivi.,'�r i'rl"�C}�y��R. ("9."�' N-�>�Sa .4.ri 'r',�' . �9 ,k C+� ,�L�'v^ .. �1 '�✓1� �°i{ er,.�""rM r t cKy°..�r'�..`., Y �e ;"i ¢ ye, „�'7r y.'��� "�, viix,.��� x.{ ^. _ a .e; r �s' +., ��.�h`� n�'4 �..i�r e 2 ri"`�q#"lif4�� ks,�iL�;� X a«`+-�-•8-. '� '": i<t°��-, r" ,,,i� � ,� r�' ��'i:��r;Y•l"�°i.�.�. r`�'A"�� -i ill.i��#'S�r�"'���PL�';w�, � t��'>ik..c�:r.. 1„ r a i ` k ''D'+ 1R r�`i.� `' :`'f"'.,^'�, •t":.r .711 „Y,S;. .rM'.yrt .� r's 'L`. 1, , mmmm i1.�- Z2TER NTY HEALTH.DEPARTMENT onmental Health Section ox 848/210 Hospital Street Mocksville,NC 27028 Phone: (336)751-8760 Ei i 1p".2 J CERTIFICATIONFO DWELLING (Check One) REPLACEMENT❑ ' REMODELING RECONNECTION ❑ Name: A Ir f �✓.j �y�'y 11 ^`'I' 'f'i Phone Number: 3 6 - 0 i Y~ T� 7/ (Home) Mailing Address: 1'70 Ce c J -14 336 14l 4--5`6 Detailed Directions To Site: r. S P+ V { c' l!'i N 1 Property Address:_ /'�M e- Please Fill In The Following Infformatignn About The Existing Dwelling JOAlbel . Name System Installed Under: `�'`AnhJ Type Of Dwelling: ` Date System Installed(Month/Day/Year): 31 1 T!I 2LNumber Of Bedrooms: .3 Number Of People:_ Is The Dwelling Currently Vacant? Yes 11 �No bYes,For How Long? Any Known Problems?Yes❑ No 8---If Yes,Explain: Please Fill In The Following Information About The New Dwelling: Type Of Dwelling: IJPJNumber Of Bedrooms: Number Of People: Requested By: � - Date Requested: (Signature) For Environmental Health Office Use Only Approved ❑ Disapproved 0 Comments: 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❑ # Amount: $ Date: Paid By: Received By: Account #: Invoice #: APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE T y (� l Davie County Health Department D LS OUR • Environmental Health Section P. O. Box 665 Mocksville, NC 27028 AUG -- 91995 1. Application/Permit Requested By a e v f'�•ems L�S-�/��e- i,..�. Mailing Address ��� �l wHOl /lel Home Phone ya-h Business Phone/ J, 2. Name on Permit if Different thin Above 3. Application for. AKGeneral Evaluation ❑Septic•Tank Installation Permit 4. System to Serve: •House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown ,.a 5. If house, mobile home:Subdivision �: N �- V,e� A C 5 Section lot #� ,,t ❑ Basement/Plumbing I' No.of People ❑ Basement/No Plumbing No. of Bedrooms 3 ❑ Washing Machine ;: s No. of Bathrooms 2 ❑ Dishwasher Dwelling Dimensionsr�.'1� ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks No. of Commodes No. of Urinals F No.of Lavatories No.of Water Coolers No.of Showers Water Usage Figures 7. Type of water supply: ❑ Public VPrivate ❑ Community : 8. Property Dimensions Sewage Disposal Contractor ? 1� 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No If yes,what type? i *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. :`,:. 1. t• Directions to Property: P rtY: e }Qct, eC j 4ejvs L N1\J tu t p S� N e n ,... f Li c�cA 1 nl� This is to certify that the information provided is correct tot st of my knowledge,and I understand I am responsible for all charges t incurred from this application. ' u l:: DATE GNAT E CONSENT FOR SITE EVALUATION TO•BE.DONE ON ABOVE DESCRIBED PROi�RTY MUST CHECK ONE: ❑ 1. 1 OWN the property. [�. 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 0 h�D vie Co my Health Department to enter upon above described property located in Davie County and owned by Gd i G'sGt < to conduct all testing procedures as necessary to determine id site's suits li for a ground absorption sewage treatment and disposal system. � DATE SIGNATURE DCHD(193) 'tp; DAVIE COUNTY HEALTH DEPARTMENT d� -- Environmental Health Section Soil/Site Evaluation o NAME =.5)� DATE EVALUATED ADDRESS 1> PROPERTY SIZE lJ CrCA9-� PROPOSED FACIILTY LOCATION OF SITE � V Water Supply: On-Site Well _ Community Public Evaluation By(Z-,jLl Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Sloe % HORIZON I DEPTH Texture group CL Consistence Structure C+2 MineralogZ HORIZON II DEPTH " J6. Texture group C Consistence F`=F Structure K D Mineralogy ) ! HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION .5 •s LONG-TERM ACCEPTANCE RATE fix+ SITE CLASSIFICATION: . J EVALUATED BY: LONG-TERM ACCEPTANCE RATE: 14 OTHER(S) PRESEIaLL- REMARKS: 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-V}..-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 Mineralo 1:1, 2:1. 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Directions to property: i�:r ; l Section: /� Lot: AUTHORIZATION FOR ! ¢ v WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION Road Name: ` 1 f�l ae, **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) ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION. IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENT HEAL SPECIALIST DATE ISSUED .crL Com-=$- : f DAVIE COUNvry HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION.. �� Permltte� �- /7 Names' �'` •wRit<'J � _ 1 �� Y� l ...•:Subdivision Name: p { Directions to property:/ '�� 1 �� ,i i`•!'*t't�'S I Section: f' Lot: IMPROVEMENT PERMIT Tax Office PIN:# �791 - Y� Road Name: **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***TILS PERMIT IS SUBJECT TO REVOCATION IF SITE �,.. .•-'',.: = �� �" 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 A #BEDROOMS "'� #BATHS_Z_#OCCUPANTS GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS I,NDDUSTRIAL WASTE:Yes or No LOT SIZE '��c TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITES REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ?X ROCK DEPTH LINEAR FT. Od OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT Y **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#IS(704)634-8760. OPERATION PERMIT SYSTEM INSTALLED BY: r - 00 AUTHORIZATION NO. OPERATION PERMIT BY: DATE: **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 05196(Revised) APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT&ATC _ - Davie County Health Department 2 Environmental Health Section D [5 O OUR P.O. Box 848 NOV Mocksville,NC 27028 4 19,W (704) 634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS A THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed i! �-Pv s u —LtJ�, Contact Person Mailing Address /!04,5"Z CPO la 3 Home Phone City/State/Zip &1daz:�n/7 2 IJ C 7 DO G Business Phone 9g 9/ `/3 419 2. Name on Permit/ATC if Different than Above Avep eZ/1 i� l t /' '� i7.�1,27 o A / Mailing Address .5r4 �/90 e U�CLI A __. City/State/Zip La SL 2L" X,)V //Y//O l 3. Application For: [ ]Site Evaluation [ ]Improvement Permit&ATC [,..moth 4. System to Serve: [IrTouse [ ]Mobile Home [ ]Business [ ]Industry [ ]Other 5. If Residence: #People-'3-- #Bedrooms I #Bathrooms e,2_ [-tl5ishwasher[ ]Garbage Disposal [�ashing Machine [�asement/Plumbing [c.Kasement/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: [ ]County/City [: ell [ ]Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes [11<O If yes,what type? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED:***IMPORTANT***, 1f OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: ya I 9/ S6 3L WRITE DIRECTIONS(from Mocksvilwl_e)/TO PROPERTY: Tax Office PIN: # �i 3 Property Address: Road Dame �i �% 6rt City/Zip 11q?O d cr If in Subdivision provide information,as f ows: Gv GJ�l Sec f/ D Name: /�✓� l�/�� //CSS � 5 1�e � JF 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. I, also, understand that I am responsible for all charges incurred from this application. 1, 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 V A-AX 2( to conduct all testing rocedures as necessary to determine the site suitability. DATE-4492— SIGNATURE Oc;h Revised DCHD(06-96) THIS AREA MAY BE USED FOR DRAWINC7 YOUR SITE PLAN: fafA 1 7885 �ro I 1 1 I 1 I I 1 Nlr __ 44&44 M 1 mase 1 1 e27A2 1 ?3f'----h I t 1 1 ——4oL __ 1 r � —, 1 I 5.004 + , 19.10A 6.02A 1 5A y , 8333 2342 7388 3411 I 1 1 1 I 1 eq.et , 1 1 1 1 I 1 i 1 ISO i asap ; i u�n x 11 r 5.00A ae R 7072 I , I I 5A $ 11 . 1 1 2951 I I ' p.73A /2871A) ; 7.01AS 7841 r � 8613 4827 1 I I 1 1 I 700 1 • I I 1 Q 2380 1aea 8285 1 1 ^ I 1 ,0 Pnoon SR 1436 i sm 1� / eo , j0 1 ►wel jean � ---- / 16.2VA) b 1 I I 5135 Scale:1'_ •••••••••• November 04,1997 9:23 AM