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171 Vircassdell Ln Well Construction Peron it 7— PERMIT Davie County Health Department [TaxLot le Nu 210 Hospital Street N Nu P.O.Box 848 1r #: kMocksville NC 27028Phone:336-753-6780 Fax:336-753-1680 uate VALID UNTIL: 9/13/2021 Property owner: Optimistic Venture Group/ Applicant: Optimistic Venture Group/ Address: 110 South Blvd. Sutie 205 Address: 110 South Blvd. Sutie 205 City: Charlotte Cily: Charlotte StatetZip: NC 28203 State2ip: NC 28203 Phone#: (704)885-0488 Phone#: (704)885-0488 Property Location & Site Information Address/Road #: Subdivision: Phase: Lot: 171 Vircassdell Lane *Proposed use of Well: Mocksville NC 27028 If Other: Latitude Longitude Directions Site Address: 171 Vircassdell Lane- Directions:Hwy 64 east,right on Dalton Road Well Contractor Information Drilling Contractor Driller Registration - Permit Conditions *Permit Conditions Well location,construction and protection must meet all state and local regulations and must be Inspected and approved by an authorized representative of the Local Health Department.The permit may be revoked at any time for failureto comply with existing regulations.The siting or approved well construction area(s)by the Health Department Is to provide protection from the known possible sources of contamination.The approved well area(s)may not be changed without written permission from an authorized representative of the Local Health Department.No volume or quality or water is guaranteed by the Health Department. *Issued By: 2140-Nations, Robert *Date of Issue; 0 , 9 , , 1 , 3 2 , 0 , 1 , 6 Authorized State Agent: (91-land Drawing 0Import Drawing Owner/Applicant Sign **Site Plan/Drawing attached.** WELL CONSTRUCTION PERMIT 229971 ea Davie County Health Department CDP File Number. 210 Hospital Street P.O.Box 848 County File Number. • MocksviUe NC 27028 Date: ,09 / 1 3 / .10 1 fi 0Inch Scale: . OBlock O Drawing Type: Well Permit wA E�V Cz 6, 71 4-1i zi _ C S i i �IfIYA' Af' RECEIVED APPLICATION FOR PRIVATE WELL PERMIT SEP 0 6 2016 Davie County,Environmental Health P.O.Box 848/210.Hospital Street DC HEALTH Mocksville,NC 27028 (336)753-6780/Fax(336)751-8786 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. APPLICANT INFORMATION Name to be Billed Contact Person 44�r&at T1AVG/�► Billing Address o Home Phone ity/State/ZIPBusiness Phone ;�oq(. $$S•0-490 Email &L.- [Name on Permit if Different than Above 6 hrw Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged OTE: A survey plat or site plan must accompany this application. Included: &Sire Plan Plat (to scale) Owner's Name Phone Number I V.$$S.O S Owner's Address o o City/State/Zip diAt &!A& to c 2m3 Property Address i City, ackku ; le Lot Size 0.G S A Mrc, Tax PIN# Subdivision Name(if applicable) Section/Lot# Directions To Site: O ff la.r--"' u;llr DEVELOPMENT INFORMATION Permit Type: New Well Well Repair Well Abandonment Other(specify) Facility Type: Residential_jo," Food Service Church Commercial Other Are There Any Septic Systems Currently On The Site? YES NO Do You Intend To Install A New Septic System On This Site? YES NO TERMS AND CONDITIONS: This application must be accompanied by a plat or site plan of the property that includes the existing and proposed property lines with dimensions,the specific location of the facility and any existing or future appurtenances,the location of any existing septic system,sewer lines,water lines,any existing water supplies and any surface waters. The applicant is responsible for identifying and marking the property lines and comers. The applicant is responsible for making the site accessible. By signing this application,the applicant signifies that they understand the terms and conditions and that they give permission for Davie County Environmental Health representatives to perform necessary field evaluations and procedures deemed necessary to determine the best location for a well. Qh��lle Signed Date Site Revisit Charge Date(s): Client Notification Date: r HS: 7/30/09 Account# Invoice# 8/30/2016 GoMaps 4.0 277 Parcels `.....: ... r _......__..____.....--...........................__......._....-......_..-.._..\.\...' .......................,. ......................._........... Y ....;..... 1 .. 151 f'f M . !! 171 \.LV..I f f� 224 y -.- r o s �r cis € T ,i 40m 200ft httpl/maps2.roktech.riettdavieNC_gm4/# 1/2 ,.Peru ittee's� �y AVI COUNTY HEALTH DEPARTMENT Name-.' I li I-Y % ,Environmental Health Section P �yE� Y INFORMATION t ,� P.O. Box 848 ✓ Directions to property; 601 �t:- ^��' ~ �--fit-� ' Mocksville,NC 27028 Subdivision Name: �l U`� Phone#:336-751-8760 ', t s tom) V o.c.vs[L'u- Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION y^-�AUTHORIZATION NO: 2299 A Road Name: l 1Vito)C�I�Z�p12, **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. ' VIRONN(ENijLyFIFAL lf-SPECIALIST "DATE 1 UEp. RESIDENTIAL SPECIFICATION:BUILDING TYPE [10)—%#BEDROOMS #+BATHS #OCCUPANTS J GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE+�+�'"LE WATER SUPPLY��TYDESIGN WASTEWATER FLOW(GPD)��D NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE " GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH `" LINEAR FT. 70 OTHER l p ! REQUIRED SITE MODIFICATIONS/CONDITIONS: I ajnt-� O N l N ��R , LET �-� ti) IMPROVEMENT PERMIT LAYOUT cr C Tin► ` �o .�>r� T 1 ` ''eor"1Zt,J 1C.5fARY **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 (336)751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: Lc�✓Id s./I'ilr AUTHORIZATION NO. ` OPERATION PERMIT BY: DATE: 119V **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE S 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 WILL FUNCTION SATISFACTORILY FQR,ANY GIVEN PERIOD OF TIME. DCHD 02102(Revised) �/ pl DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990001812 Tax PIN/EH#: 5757-18-6114 Billed To: Daniel Hughley Subdivision Info: Reference Name: Location/Address: Vircasdell Lane-27028 Proposed Facility: Residence Property Size: see map ATC Number. 2914 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 m etion shall indicate the system described on Improvement/Operation Permit has been installed in compliance icle 1 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in N WA bet en as a'guarantee that the system will function satisfactorily for any given period of time. i 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 #: 990001812 Tax PIN/EH#: 5757-18-6114 Billed To: Daniel Hughley Subdivision Info: Reference Name: Location/Address: Vrcasdell Lane-27028 Proposed Facility: Residence Property Size: see map **NOTE * &m is 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 -2 #Baths 1 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 Design Wastewater Flow(GPD) 15 0 Site: New Repair❑ System Specifications: Tank Size/ Al /-V//- GAL. Pump Tank GAL. Trench Widt lei Rock DeptLinear Ftd Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6°G 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: Date: DCHD 05/99(Revised) (1()AlLI ON FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC • D `"1 Davie County Health Department Environmental Health Section JUN 2 ' 2001 P.O. Box 848/210 Hospital Street ,; 1"L ey/Se Mocksville, NC 27028 (336)751-8760 ENVIRONMENTAL HEALTH LICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS VIDED. Refer to the NFORMATION BULLETIN for instructions. F1 1. Name to be Billed p / /� * Contact Person Mailing Address 1! /L�- Homd�honeML 7 City/State/ZIP l.t_J 'S^ C- Business Phone- 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. ApplicationFor: Site Evaluation Improvement Permit/ATC Both 4. system to Service: Ouse ❑ Mobile Home ❑\Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms # Bathrooms f ❑ Dishwasher ❑ Garbage Disposal )11�ashing Machine O Basement/Plumbing ❑ 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: NX County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes LIo If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBM17TED by the client with THIS APPLICATION. Property Dimensions: �'P h'" / WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: # (-0`( /— -:3 ;v-, f Q b N Property Address: Road Name D l r caS.V e l/ "/LC- City/zip. `City/zip h-. Cis✓ CL 5��L�' _S te i S If in a Subdivision provide information,as follows: Name: Section: Block: Lot: 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 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 Coun and ned by to conduct all testing procedures as necessary to determine th site suit bility. DATE SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the follow' g: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). o Site Revisit Charge Date(s): ((((JJJJ Client Notification Date: EHS: 3 Account No. Revised DCHD(07/99) /"�/ Invoice No. DAVIE COLNW HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001812 Tax PIN/EH#: 5757-18-6114 Billed To: Daniel Hughley Subdivision Info: Reference Name: Location/Address: Vircasdell Lane-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: 7 61'01 Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope% y HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure MineralogyC HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: -2 . OTHER(S)PRESENT: 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 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 Wet 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 Notes 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 05/99(Revised) ■■■■■■■■■■■■■■■■■■urs■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■/■■■■■■■■■■■■■■ ■■■■■■t■■■■■■■■■ti■■■■■■■■■■■■■■iii■■■■■■■■■■■a■■■■■■■■■■■■■■■■■■ NOMINEESEENNEMENNENMENNEN ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ I, THOMAS A. RICCIO, P.L.S., CERTIFY THAT ON MAY 29TH 2001, WE SURVEYED THE PROPERTY SHOWN ON THIS PLAT; AND THAT THE PROPERTY LINES AND LOCATIONS OF IMPROVEMENTS ARE ACCURATELY SHOWN' HE4ON; THAT, EXCEPT IF NOTED, NO IMPROVEMENT LOCATED ON THIS PROPERTY ENCROACHES ON ANY ADJACENT STREET OR PROPERTY, AND THAT NO IMPROVEMENT ON ADJACENT PROPERTY ENCROACHES ON THE PREMISES SURVEYED. '�] /� / C-- ,'-� `---�_ L-2815 LEGEND PROFESSIONAL LAND SURVEYOR EIP EXISTING IRON PIN IPS IRON PIN SET •`y, PARCEL i � JN0000002001 �`• ' •�' NIF LILLIE S. DALTON DEED BOOK 69 PAGE 36 i i i STAINLESS STEEL PIPE PARCEL J600000019 N/F LILLIE DALTON DEED BOOK 59 PARCEL PAGE 74 J60000002008 ,ah ( N. C. DALTON ET UX oti �� 000 DEED BOOK 133 PAGE 695 o. 0.65761 ±A °-, rA BY COORDINATE COMPUTATION PARCEL A a,, J600000019 '� ��' 1a,, PARCEL 00000016 ph�ti�I POLE` -_ RIIEgD UTILITIES 4 �'- `�� Y \PS N 82°19'28"w EIP E�- �M PA - -- 130.79' 30 1 PR 5.�� 71` EIP PARCEL ATE PA L Jd 74. 0,T, J600000016 ,. E�IiEN IE NATHANIEL DALTON ET UX DEED BOOK 58 PAGE 156 EXISTING STONE / / PARCEL J60000002007 C.N. DALTON ET UX / DEED BOOK 123 PAGE 65 DALTON ROAD U. S �CyAgY eq / SITE VMCASDELL LANE LOCATION MAP NOT TO SCALE SURVEY PREPARED FOR DANIEL HUGHLEY,_ SR. PLAT BOOK SHOWING THE NORTHERN PORTION OF TAX PARCEL J600000016 ]PAGE TAX LOT BLOCK MOCKSVILLE TOWNSHIP * DAVIE COUNTY * NORTH CAROLINA FIELD: TR WM NM DRAWING 01173 ADDRESS: VERCASDELL LANE DATE: 05-29-2001 MAPPED: TAR ]NUMBER THOMAS A. RICCIO & ASSOCIATES PROFESSIONAL LAND SURVEYOR 0' 30' 60' 120' 180' 440 WEST END BOULEVARD S C A L E: ONE INCH EQUALS SIXTY FEET WINSTON-SALEM NORTH CAROLINA 27101 336-773-0211 s its To' '3a�`, e. .� ��a ��.'3�� r� ¢��,,_. z ✓ _� t"' ,� ��,t� x �,:� � ��"�*ri,�+�a��i r�E m..•y � t k ti•- <tt; �•A^'A'« 9 � +`� �y+Fs f as•� "�,�,tlrbX+, � �"#,# +`'�1��'�.'w`' PF 'a'rM' _:_� tr �'r�. t t 7�,. �y : pe e"�' ' �,"�tf �v�.�4,,¢�.,fitY +�. t .Y �, x.,',f� 's� a ,�• ;. Fa �y LJ � :. �� 7 ,ro. •�} Y v;A"' ry�nik� +" � "� � �'� �.�- 'f'�i � �kr•„ � �L._ � � �� {v ,z#:1' �,`fit y �`` }� � ,,"�£ "" ��. ' •� � � �� .� �+ �' :-_ ', «M�yr+w#ey ^q��., �.�'<._a �d,Lw.�•f� 'y�µ add, '- �ss �t '."S � . s ( a DOlwfli ��k Baa '�<' � �._ t �z .r *•• �°"� :: �� :, c � TOP N $ �'� Y� :PA a fiyr�A e •.j� d'_s,A" ad5 '' a F'� �%;, 1�y, d S< , 'dp)�;,�t .t. M, 4��kro. '$:, � �RZ �: i" ,K,� d•• MOWS! is '=��W�' t•,w�r � � -�4 �d X4-3, � �` � "w �� { #� r,� 'tdr •qua 9 P ` + �.. �. «qn I ��' '.� s �� .#' � r r^.,y "�.'� ry +'+` � ,, h. ,� Q j ML- to � �' �' �' k7f•�� rLt*,P �..dyr l3� ��'. ` + � � 1dA � / 3 �• � � f� 5rw9 ��3l vF}. All:, M _rq ess... *fit �; "q��""¢, �� 'f, Fy 1M•; d y r,s -y r.�Mpg7 mm 'a 'PA V, r "•a 4Sr 4 bt •.w, iA 2 Y. 'a¢ '`7r8 # s T# t?, �1' �'fo r WIN i. "'ai T%-r ,�` •...`6(`ak Y�g�3� X''�idr� 6 6` }`„�: �� „� x��'�'..SP xP• �' Y �t�� ''�� ,^ e Y�,.� fi>` 'ys'�� d F � � � fir- �- ' j 4w �ras �a,eQ ,«�k� �� « g � ,y i, 5- `�'� dk;;> �y �! s 6 �s � `s y,;s�.��` }r�}+iq+••1 14L5, MOM �� >Sl;s��9��r A -`" Y �Y ;�;, � � i k '° a h � Y •, � r� ", ��.Q6g�i �a*�`�` � ¢:s zt e' _ ...rF #' fi �i X� t•s r +. i¢> t r y'k,° g, W59,9) f'IA .+ ��'t " � ��ar � P� � � � 4 �' a ., ESQ � '� '�� >%'��' +�� ; ,��` �•';_ AW-1 ��.�•s 3 : A1C � -{ J �. �' r n.� � 3 z "�y d} � � >e t ,�.�•' � z � ��' �� z �' rte, t �,� a�' �• # P� xP} '. �! # P y. ., t t a tiL _ Yq2 # € LV 4L �«�w�;,%;•�'�,..,,,dna ,..�. ... _ O P664 Mare Nell Richic /' ryi4n, Tax Administrator o(J �y�C DAVIE COUNTY TAX OFFICE 123 South Main St Mocksville, N. C.27028 Telephone 336-751-3416 Fax: 336-751-0154 Applications for certification that a property owner owes no delinquent taxes for the purposes of obtaining a building permit. 1. PROPER'T'Y OWNER: i1 c,c h (w15jl ACCOUNT#: d 2. PROPERTY OWNER ADDRESS: 195 Otct.t, it- l., 3. MAI' NUMBER: Q af- Y!::fT I ; - I (� 4. PIN NUMBER: l j - ) ^ (1, ( 19 5. DESCRIPTION OF IMPROVEMENT, new dwellin T addition to existing dwelling, garage, shop, farm building, etc.) 6. DIRECTIONS TO SITE: c 7. APPLICANT(J- `-� DATE: a APPLICATION FOR CERTIFICATION APPROVED: The office of the Davie County Tax Administrator certifies that the above named property owner owes no delipquent taxes as of the date above. - - d ................................................................................. APPLICATION FOR CERTIFICATION DENIED: The office ofthe Davie County Tax Administrator denies certification. The reason being that tlfe property owner named above owes $ in delinquent taxes as of the date above. TITLE: DAVIE COUNTY tiEALTH DEPARTMENT f Environmontal Health Section • P.O.Box 848/210 Hospital Street O Mockgville,NC 27028 (3.16)751-8760 IMPROVEMENV()VE-RATION PERMIT Account #: 990001812 Tax PIN/EH#: 5757-18-6114 Billed To: Daniel Hughley Subdivision Info: Reference Name: Location/Address: Vrcasdell Lane-27028 Proposed Facility: Residence Property Size: see map qqT mb r: 2914 **NOTE * This�mprovement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATI"It SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installatiou of a system or the issuance of a building permit(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Sy'+torr+S, Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION II'SI'1'1;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 Type Water Supply ()c<+i + Wastewater Flow(GPD) Site: Newf2' Repair❑ ,, t System Specifications: Tank Size GAL. Pump Tank ___GAL. Trench WidttL� Rock Depth 6911- Linear Ft,,W Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- A/ pROVED EFFLUENT FILTER RISERS)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.►n. un the day of installation. Telephone#is(336)751-8760.**** jjj 7 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 Account #: 990001812 Tax PIN/EH#: 5757-18-6114 Billed To: Daniel Hughley Subdivision Info: Reference Name: Location/Address: Vircasdell Lane-27028 Proposed Facility: Residence Property Size: see map ATC Number. 2914 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 1 I 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: l CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of etion shall indicate the system described on Improvement/Operation Permit has been installed in compliance icle 1 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in N WA bet en as a guarantee that the system will function satisfactorily for any given period of time. Septic System Installed By: / Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised)