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114 Sunburst Ln Lot 2 _ as DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section G P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900640 Tax PIN/EH#: 5735-38-0207.02 St' Billed To: Bruce AndersorY ROGER SPILLMAN Subdivision Info: Sunburst Heights Sec.2 Lot#2 Reference Name: Bruce Anderson Location/Address: Junction Road-27028 Proposed Facility: Residence Property Size: 3/4 Acre 0EC*Toee**Ns rmnt/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: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 141t C Type Water Supply ' Design Wastewater Flow(GPD) d Site: NewX Repair❑ System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width Rock Depth.42 Linear FtT o Other: 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: e4Date: DCHD 05/99(Revised) j .. 1 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account M 989900640 Tax PIN/EH#: 5735-38-0207.02 Billed To: Bruce Anderson/ROGER SPILLMAN Subdivision Info: Sunburst Heights Sec.2 Lot#2 Reference Name: Bruce Anderson Location/Address: Junction Road-27028 Proposed Facility: Residence Property Size: 3/4 Acre ATC Number: 2378 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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: 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 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 will function satisfactorily for any given period of time. 110' 2 t , ];s 100 rt Septic System Installed By: n.,J Environmental Health Specialist's Signatur Date: Tiy DCHD 05/99(Revised) APPUCA11ION FOR SITE EVALUATION/IMPROVEMENT PERMIT& A= r2 fn �I Davie County Health Department 3[WR EnvironmenfalIfea/ffi Swf3on P.O. Box 648/210 Hospital street 5 2000 Mocksville, NC 27028 (336)751-8760 « ' ENVIRONMENTAL LTH ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be 9111ed ©a cv_ I YVIcl contact Person /--')01 e Nailing Address sU r C 3 v Have Phone (('�� J✓1,, City/State/2IP je- Business Phone 2. Name on Permit/ATC if Different than Abw(erI.t(�C9 LINA-e Y, SO 1� l Mailing Address l...CXy'V Li AQ 1�1� City/stat�e/zip M,O c-K''/�Sy �[ 2— 3. Application For: U Site Evaluation 4-f rovement Permit/ATC 0 Both 4. system to service: ❑ House &Itobile Home 0 Business ❑ Indusltry Jj t^' s. If Residence: # People # Bedrooms DC # 1QQooms &Dfiii asher U Garbage Disposal G-I aashing Machine O Basement/Plumbing l] Basement/No Plumbing 6. If Business/Industry/other: Specify type # People # sinks # Commodes # Shovers # Urinals # Nater Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) A 100* . 7. Type of water supply: "County/City 0 well 0 Community s. Do you anticipate additions or expansions of the facility this system is Intended to serve? ❑Yes 0 No If yes,what type? ***IMPORTANT"**CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either s PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: �7 C/`e WRITE DIRECTIONS(from MockM11e)to PROPERTY: Tax Office PIN: # 02— CA Property Address: Road Named C7%� -LA v-x eT i O✓1 -Pa s3 City/Zipkv"Ile- .yG2e If in a Subdivision provide information,as follows: FO Vli— C1 CZ f Name: v 1.1 V1 lel r S �i Jev u , Section: _ Block: IiA— Lot: Property Flagged: 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 responsiblefor aft 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 sui ii DATE 5 0 SIGNATURE f THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Eristing and proposed property lines and dimensions, structures, setbacks, and septic locations). Account No. Revised DCHD(07/98) Invoice No. �� 4 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&AT r' VIE Davie County Health Department EnWivamenla/Heafth Section � 8 P.O. Box 848/210 Hospital street im Mocksville, NC 27028 (336)7S1-8760 ***IMPORTANT*** THIS APPLICATION CANNOT.BE PROC,BSSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructi�o,(ns�. 1. Name to be Billed r(/nDx '7 Contact Person V iin Mailing Address _ _A) 6 39 Bam Phone City/state/ZIP Cook YW-0- ,`c pJ70)(1 Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: d"3ite Evaluation ❑ Improvement Permit/ATC 0 Both 4. system to service: 0 House (Mobile Home 0 Business 0 Industry 0 Other s. If Residence: # People4�-" I # Bedrooms # Bathrooms 0 Dishwasher 0 Garbage Disposal 8'Rashing Machine D Basement/Plumbing 0 Basement/No Plumbing 6. If Business/Industry/other: specify type # People # sinks # Commodes # Showers # Urinals # Nater Coolers IF FOODSERVICE: li Seats / Estimated hater Usage (gallons per day) 7. Type of water supply: 0"Connty/City 0 Well 0 Cononmity e. Do you anticipate additions or expansions of the facility this system Is Intended to serve? 0 Yes ❑No U yes,what type? ***IMPORTANT'** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN AIUST RESUBMITTED by the client with THIS APPLICATION. Property Dimensions: — WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: # ( aa I., V � Property Address: Road Name= City/Zip,LI1n �f5/!)UL 02 702 If in a Subdivision provide information,as follows: Name: � blt nJ`� �e'-Vre'-'X� Section: Block: Lot: 1�c Date Property Flagged: 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 responsiblefor all charges incurred frons this application. I,hereby,give consent to the Authorized Representative of the Davy County Health pepartment to enter upon above described property located in Davie County and owned by r U U— to conduct all testing procedures as necessary to determine the site suitabilih. DATE "1 / SIGNATURE lE d4d", � THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Account No. d577/4-2 Revised DCHD(07/98) Invoice No. ✓�