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199 Tom Crotts LnAccount #: 990003055 Billed To: Shanna Crotts Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5756-57-1524 Subdivision Info: Location/Address: Tom C Lane -27028 Property Size: 2.598 acres TE **NOS* This 3692 is mprovement/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 %2y #People #Bedrooms �—P #Baths Dishwasher: Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply tllVell_ Design Wastewater Flow (GPD) Site: New Repair ❑ System Specifications: Tank Size GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width f C Rock Depth /3"' ,Linear Ft,*Zl)� 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: All Date: "o DCHD 05/99 (Revised) Account #: 990003055 Billed To: Shanna Crotts Reference Name: Proposed Facility: Residence ATC Number: 3692 Tax PIN/EH #: 5756-57-1524 Subdivision Info: Location/Address: Tom C Lane -27028 Property Size: 2.598 acres DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003055 Tax PIN/EH #: 5756-57-1524 Billed To: Shanna Crotts Subdivision Info: Reference Name: Location/Address: Tom C Lane -27028 ATC Number: 3692 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: 4 q / / 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 11 of G.S. Chapter 30A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WA uaran that the systerq V�ction atisfactorily for any given period of time. -} r jfS i V-- Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) Account #: 990003055 Billed To: Shanna Crotts Reference Name: Proposed Facility: Residence ATC Number: 3692 Tax PIN/EH #: 5756-57-1524 Subdivision Info: Location/Address: Tom C Lane -27028 Property Size: 2.598 acres E t U E� �r I 1 FEB - 9 2004 l� 1. ENVIRONMENTAL HEALTH PLICATION 17011 SITE EVALUATION/IAIPIIOVEAI ENT PE-11M1T & ATC Davie County Health Department Enviroa1nenta/He,7&11 Section P.O.. Box 848/210 Hospital Street I Mocksville, NC 27028 (336)751-8760 RTANT*** TIIIS APPLICATION CANNOT iiE PROChSSLD UNLESS ALL TIIE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. i� 1. Name to be Billed Y1� k'I;,' Contact Person t tmtLl t Mailin ress home Phone City/State/ZIP Business Photic 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: Site Evaluation 2-11mprovement Permit/ATC ❑ Both 4. system to service: ❑ House F;,Vxobile Home ❑ Business ❑ Industry ❑ OL11cr 5. Type system requested: ❑ Conventional ❑ conventional modified ❑ innovative 6. If Residence: It People _ It Bedrooms 1-9— 11 Bathroontu 194ahwasher ❑Garbage Disposal 57`ashing Machine 7. If Business/Industry /other: verify type It Commodes It showers ❑Basement/Plumbing ❑Basement/No Pluwbing It Urinals It People It :;int::; it Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) _ ____ 8. Type of water supply: ❑ County/City Dell ❑ Conununity 9. Do you anticipate additions or CXpanSi011s Of the facility this system is intended to serve'! ❑ Yes'11 If ycs, what t)'pc? ***IAIPORTANT*** CLIENTS AiUST COAIPLETETHE REQUIRED PROPERTY 1NFORNIATION REQ01"'S E'D BELOW. Either a PLAT or SITE PLAN AIUST BESURKITTED by the client wilh'l'I(IS API'LICA'I'ION. Properly Dimensions:, Tax Office PIN: #^,-�)�152�1 Property Address: Road Nanle —I f n Ozone—, city/zip Met .I NC's a(7oW If in a Subdivision provide information, is follows: Name: WRITE DIRECTIONS (f -our ModwIlle) to I'ItUI'hI('I'1': �Aurq ,b 7— mii�S6�fl Y-bi — t -s -For,&C 1YcCI-b I )im P i1-nP v\k\w -h-r-r° 4 - Section: Block: Lot: Date lionlc corners flagged: ( �I This is to certify that the information provided is corrcc the best of my knowledge. I understand that any pernlil(s) issued hereafter are subject to suspension or revocation, i the site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that I aur responsible for all charges incurred f -oln this application. I, hereby, give consent to the Authorized Representative of the D' vie Count 10.11 111 1)Cpartuleu( to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitalbili_t)'. DATE . 2 SIGNATURE TIIIS AREA MAY BE USED FOR DRAWIN OUR SITE PLAN (Inclu a!c 'ollowing: Existing :old proposed property lines and dimensions, structur 5 a an sep 'c loco V�I r �C Sign given Revised DCHD (05/03 Site Revisit Charge Datc(s): Client Notification Date: LIIS: Account No. Q Invoice No.—� /� ..�r irc. �,� ' E , ,� , ,, ,ii., ,,,,%,,,.r , F ��. �, ... � � .�� . � 6„ �T, N�CaATI� �, � �'�; �$p� � _�� N , � ��, _ _ , p � , ' .. 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