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1664 Yadkin Valley Rd � , DAVIE COUNTY ENVIRONMENTAL HEALTH � P.O.Box 848/210 Hospital Street Mocksviile, NC 27028 (336)753-6780/Fax# (336)753-1680 . REPAIR OPERATION PERMIT . c Accou�t #: 990005998 _ '� '��x F�l�f,%�H#: C600000118 ' -.. �. ._.. �iElcsi� Ta; James, jj0�/�PS _ Sut�ifivi:.,iori lr��c�: : , . __ _._ Refer�E�c� P��€��e�: REPAIR _ , � Locaiio.niAdi�r�ss: 1664 Yadkin Valley Rd-27006.: . � F�ropc�s�:d F'��:iliEy: Residental Repair � ;-,, ,,., �fog��rf.y�S�ix.�: � .885 Ac . ., . t�TC*E�CD�#* 'I�@9�'suance of this Operation Permit sliall�indicate the'sysfem described on the ATC 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. System Type:�_S.T.Manufacturer P � �b Tank Date �� Tank Size � , Pump Tan�c Size ` Bedrooms � ► System Installed By:� t/ C�it.��' Installer#: Date:��j GPS Coordinate: , . ��C- �"�4�� °�S � �rn�� o �ti�� , � � d SP��.C� ��w1 ��n ��? I Jh� 1. . �� . l —� � � Environmental Health Specialist: I� Date: Z� Z�� 3 i - - . DCHD 11/06(Revised) ,� . � , • DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/Fax#(336)753-1680 . AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRLJCT101Y � �Cct�u�lt ##: 990005998 . ' � i"�x.F'INi�I-�#: C600000118 . . . Bille� Tc?: James Bowf�eS ; ��at�i�i:.,ic�n lr��o: }�efer�r�ce P�ani�: REPAIR : : . � :- '• LocaiiorifAddr�ss: 1664 Yadkin Valley Rd-27006 : ` ", ` Pro�osec9 F;��:ility: Residental Repair r:��.,, : ` : . � l�rb��rfiy S�iz�: .885 Ac _ ` , , Site Type: ❑New �epair OExpansion ��T'C Nu�tb�r: 6016 , �. **NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to.issuance of any building permit(s),(in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FNE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. . . - Residential Specifications: #Bedrooms�#Bathrooms 2 #People � Basement0 Basement plumbingG Non-Residential Specifications: Faeility Type # People � #Seats • Square Footage(or Dimensions of Facility) � Lot Size � S Type of Water Supply: �County/City ❑Well OCommunity Well System Specifications: Design Wastewater Flow (GPD)�Tank Size IbLO GAL.Pump Tank �GAL. Trench Width '-f Max.�Trench Depth / Rock Depth / Linear Ft .� Site Modifications/Conditions/Other: Contact the Davie County Environmental He�lth Section for final inspection of this system between ' 8:30-9:30a.m.on the da of installation. Tele hone# 336 751-8760. �� • �^ ` � �� 5 � � —� \ �v� , \ '4 �� 7 . . � � Environmental Health Specialist • Date:-'ll�/ �� _� DCHD 1]/06 (Revised) �� ' . DAVIE COUNTY I�ALTH D�P�',RTiiT�tT S�PTIC TANK PII�:�•IIT �� s� No. of Bedrooms � Date ` This pex�mit is granted to �'�""�=�1..� �r the installation of a Septic Tank at the residence of . �,�Address � 1. .-T-- Building Contractor Address .� �� - Septic Tank Specif�cations; Length �� tididth�Depth Capacity �� Gal� T-Zanufacturer�s Name ,�2' ��- Address � No. of lines �+Zlidth ,� 6 in. 2'otal length ,�6U �`t. No. of Sq.F`t._ �p0 Type of f5.lter material �� Total tons used �� Nlinir�n ftequirements: Tank Ca,pacity Square Ft. of Line House Trai.ler �s00 1�00 Trro-Bedroom House 800 600 Three-Bedroan House 900 900 ' No one sha11 install a septic tank in Davie County without a perr�it from �,he Health Officer or his agent. Date of final. Approval Signed: ' Sanitarian I hereby certify that the above septic t ank has been installed according to sp�cifications. Signed � Septic ank Contractor Note: Make sketch of disposal sys�en on bacic of sheet and mail to the Health Center in Tiocksville.. • . . . '� �, �` . • ' ' ` � ..... . _....._. . _.. . _ . . .. . . � . ` . . ... . . . . . . _._ . �� .. - . . _ , . . � .. . . . . . . .. . ' _._.....-.. _ .. ... . . . ... � �... . , . .. , _ . .. p� . "r.S _ . _ ' � • � _.. _ , .._ . ..._ . .._ . •. . . . . .. . ... ._ _.. . 1 � . . _ . . _ .... . . . . . • . ' - ' � ., ,.,, . .. s �c . a � .. - .� .. . . r. � ,��..� ..`,�.,�..,r,...7 +�t� .;.. r��.y..... a,�..��n.,�,.,�,r;y.iZ'�^.#'"*fi'm+^ys�.ns.,�0'^ . Au HORIZA7�'v� � �;'�� DAVIE COUNTY HEALTH DEPARTMENT ,: ; / "�- � `�S u J ' �, . , ,. ;, ,, , , , , � : , ., � ,; „ `. " � • ;Environmental Health,Section ' .PROPERTY INFORMATION �� rmrttee �.--=�* �� ` P O Box 84$:' �� ': �� r 'YName:�T�r•''�' ��'� < .,, Mocksv�lle NC 27028 Subdivision Name `� ' ' '� � Phone#.336 751-8760�>� �'� Directions to property �' ,»� t'` t °� ; Section: Lot: , ` ,/ ,. AUTHORIZATTON FOR '�� r .�,�'�'!�� _ ' WASTEWATER Tax Qffice PIN:# - — �SYSTFM CONSTRUCTION '. �1�frr'r,,,.v�-�'"r,"' , R�ad Name: `Z�p:_ �� .. . �� , . :. . � . „ , . ,.,. **NOTE**'This AuthonzaUon for WaS[ewater,$ystem ConsuucUon MUST BE ISSUED:by the Dav�e County Environmental Health Section prior - to.issuance of any'Bu�ldmg;Perm�te 'Th�s FormlAuthonzat�on Number should be presented to`the Dav�e County Building Inspections ' ' �� Office when applying for,Buildmg;Permtts ' (ln�comphance,,w�th Article:l] of G S Chapter.'130A Wastewatei Systems,Section 1900 Sewage Treatment'and Disposai Systems) ^+i r;:. ' ' ✓� '✓' ;) ` �y' '' ,,.j ***NOTICE'�**THIS�AUTHORIZATION FOR WASTEWATER CONSTRUCTION ��,r r{ � �(:�� ..��' '"` �`c�,i�r'""'�� ,.� �r!o�L� �: ° ;.` `' `'; IS VALm FOR A PERIOD OF FIVE YEARS.�' ' ` —, r, .:EN RONMENTAL HEALTN SPECIALIST ;', ;<'RATE,ISSUEQ ` �� t �,s; � ` i�z �, � �; << i ' ;� RESIDENTIAL SPECIFTCATION.BUILDING:TYPE �`� �,#BEDROOMS " #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes orNo ,'; � COMMERCIAL SPECIFICATION FACILITY TYPE #PEOPLE #PEOPLFJSHIFT #SEATS INDUSTRIAL WASTE Yes or No : � - , � , � � . , , ti �; ; ��,r , r �" f � � ,� ; �' , `:�: LOT SIZE y TYPE WATER SUPPLY �V ' �' DESIGN WASTEWATER FLOW(GPD) NEW SITE� ' REPAIR SITE-� Y r I�� . �� , .. '.. �1 . _. . . ' ,_� i.� i ��. . SYSTEM SPECIFICATIONS: TANK SIZE '/�GAL PUMP TANK GAL. TRENCH WIDTH ` ROCK DEPTH LINEAR FI'. � OTHEK �i�! ' �vi'�l.�.1 .fil�J� R�QUIRED�SiTE Iv10DIFIQATIONS/CONDITIONS i � �IMPROVEMENT�PERMIT'LAYOUT .�APPROV�I}.,EF��,.I�ENT,�F�LTER'�` ,'�R�SERtr'a) I�'�:G" H�L.DW��F�NI�HEU GRAAE� � 3, r a� ff y y i � i �i, R d, ',i � �. 4� f.. „. � ��:A f '.. �✓: ��/ — l �l� �� , **CONTACT A REPRESENTATIVE OF:THE DAVIE COUNTl HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM ' ` BETWEEN 8:30 9:30 A.M,OR 1 00-1:30 P M:ON THE;I7AY OF INSTALLATION.TELEPHONE#IS(7��$��; ; , . '' • ' � ,. .,�� . ' . �� .. : ' '' ,.` �� , � �(�3fs')'7``J1-876�� ' ,� OPERATION:PERMI'I' " ' SYSTEM INSTALLED BY: z - ,. � , . �: � i �/�/ ^ q ��V � �� , , , �/ i i� /y��" uy J/T , �. •- ! J � L � � � �g� PERATION PERMIT� � � � � •� � �� DATE: . ,, . , AUTHORIZATION NO. � O BY r � � I �, , . �,. , , ��, � **THE ISSUANCE OF THIS OPERATION PERIvITT:SHALL INDICATE THAT THE�SYSTEM DESCRIBED ABOVE,HAS BEEN INSTALLED IN COMPLIANCE, . , —:. � WITH ARTICLE',l f OF G.S.CHAPTER 130A;SEGTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS";BUTSHAL�I.'I�ti�N0.�1.4�BE TAKEN A5'A° GUARANTEE THAT THE SYSTEM WII..L FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. k DCHD OS/96(Revised) r � . �� `` , , , , � � ,`�• l _. � . ._.... . ::,t , _ _� ._:�.�.,. .. �, .. .. .... ... .. .. . . . . �' � '�,. �'� . Davie County Health Department PV L,��„�� . � 1836j'� � 1,;�w- � onmental Health Section � .,,,..� . .�� : f �� . P.o. B o X s�s , � � � �: 3 ��!� � `'� ;'`, ''� 210 Hospital Street � � � . O U �'t dY� Courier# : 09-40-06 "• 1911 Mocl:sville, NC 27028 Phone:(836)-753-6780 ON-SITE WASTEW � FICATION Fax:(336)-753-1680 (Check One) Replacement emo elin Reconnection r Name: 27(,t) �5 Phone Number ��—�`"f�� (Home) Mailing Address: � (Work) r Email Address: Detailed Directions To Site: �RO� 7�D �AST�. �;�,Tlg��r-n J �' - o nt a /��f N/'i�( �C�.c!�I��p�b x a m i '�'o vqd�r�//��o�rn on� �,'�l��.�� Prope Address:��(oC�- �f ��_�G`�e_�,��. ��1-oa�� Please Fill In The Following Information About The EXISTING Facility: , ��5 ��• Name System Installed Under: Type Of Facility:J'�_�p�/�`i e�/1/2 e Date System Installed(Month/Date/Year):__1`'J(�,� �'' Number Of Bedrooms: �. Number Of People: � � � a..o�b� � � lla�er' LUj�II rn ove- � l t Is The Facility Currently Vacant. Yes No If Yes,For How Long. /L �}�� Any Known Problems? Yes � If Yes,Explain: ,�� Q/�l�,/ / /UQ(,(� • l� Please Fill In The Following Informatio About The NEW acil'ty: Type Of Facility: O (Si JI `� / ��sdmi�er Of Bedrooms:_�Number of People � Pool Size: Garage Size: Other: Requested B}{. ��6n�,U��_��i1/ Date Requested: S ignature) For Environmental Health Office Use Only Approved Disapproved omments: �.Q��.S �6 iY!(9l.tl��T �G I�G�,vt�L �`�R�/'��`�iTn �l�pl��/ Environmental Health Specialist D 1 Date: //%/�/.3 *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 Chec Money Order # Amount:$ �(�� Date: � Paid By: �Ie$ Received By: Account#: �� Invoice#:__ ZS�� .,.a�.� _ �. �..,.�_�-� .�.� . � ------- _ _ __.._ __-�_— _ -- — � , � �, � � � � x. ., I ;, ' �� ,t;� �,� , � _ � '. : �».� �, -. � � �, -� g �� , � � � � � � � � � �' �: � ` '�`�`�--� ��' � : �, Y i „� �� .y z� -�- � �� ,� `� � ��=:� �� j � �- ,� �� - �•�r~��:� �,� �� - , . , '-1--� . . . .�. � � �� , � � � r . , ._ �.� . ^� � "� ��' �� k `�"�,�", 166� �� . ... �_. �.. . _ . ��",.:�. � �. d �. �', °.- _ . . .� � �:_ `� ''� .� �� #'+i �� rr � � 9 a,. �-. �` rrt , . , ..+ , � �. � L 4 � �� , � ; ' Y � :�,�w, rf - ''= , y . ,, � *- + � ' -�»--.. x. � �:� �� - ��"��`a � �. � -.�c,.,� _, , � __ � •_ � �f , # .r.�, . _. �# . .v tt P� ` ' �� ... . �m. .. .*w.....� �� e - . �, Ai�. v. ,�. "� ': �..,K �� ..� . .� _ � �.., � . .. .. �F e p. � _.. _ u.�� S � �(��' �'�"'"` _;,� ' � A,� ',�.,� ' �!'. � � �-+�` � � � h <: � �,%"� _ ,. . 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'. .� -. �. .. .,. . �.....-�' . �. . . w. , q. � �t APPLICATION FOR SITE EVALUATION/IMl'ROVEMENT PERMIT & ATC Davie County Environmental Health P.O.Boz 848/210 Hospital5treet Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 Application For: � Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Type of Application: ❑New Svstem �Repair to Existin�System ❑Exvansion/Modification of ExistinQ System or Facility ***IMPORTAN7***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPT.TC;ANT TNFnRMATT(lN Name Contact Person � �rnp s�,.�1 es Address Home Phone �q��(�� City/State/ZIP,�G� �'.nrL e��y� �t �aCp Business Phone Email Name on PermidATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE:_ A survey plat or site plan must accompany this application. Included: ❑ Site Plan �Plat(to scale) (Perniit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name' ',�J'r,C;�� c, �O �-�ieh n�� p�,�}jQ S Phone Number�g�6b Owner's Address j City/State/Zip_,2�� Property Address , �� City Lot Size (,��4 C Tax PIN# Subdivision Name(if applicable) SectionlLot# Directions To Site: C F'fl� '= P 5� "� � L If e answer to any f the following questio is�"Yes",supporting documentation m t be attached: Are there any existing wastewater systems on the site? �Yes No Does the site contain jurisdictional wetlands? Yes �I�To Are there any easements or right-of-ways on the site? Yes LlNo Is the site subject to approval by another public agency? �Yes No Will wastewater other than domestic sewage be generated? Yes dNo TF RF�TI)�NCF,FTT,T,ni TT THF,RnX RF,T.nW #People Z #Bedrooms � #Bathrooms _� Garden Tub/Whirlpool OYes �No Basement: �Yes ❑No Basement Plumbing: ❑Yes ❑No � IF.NAN-RF,STDF,NCF.,FTT 1_,nIJT THE BnX�iFI.,OW Type of FacilityBusiness Total Square Footage of Building #People # Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: �Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: �County/City Water ❑New Well ❑Existing Well ❑ Community V�e�l Do you anticipate additions or expansions of the facility this system is intended to serve? C�Yes ❑ No If yes,what type? L'�x_..C.Z._1�.�»1 _._.__�_._.,-----_____.___..._. This is to certify that the information provided on this application is true and correct to the best of my lrnowledge. I understand that any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to detemune compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and comers and locating and flagging staking the house/facility location,proposed well location and the location of any other amenities. r perty owner's or owner's legal representative signature Site Re�isit Charge Date(s): � '��,j Client Notification Date: Date EHS: C� 1' � �2�� 9 Sign given ❑Yes ❑No Account# Revised 11/06 - Invoice# . Appraisal Card Page 1 of 1 DAVIE COUNTY NC '" 1/9/2013 12:04:44 PM BOWLES lAMES C III RIDDLE P S Return/Appeal Notes: C6-000-00-118 1664 YADKIN VALLEY RD UNIQ ID 2123 � 068000 D128-P8 ID N0:5863215873 � COUNTY TAX(100),FIRE TAX(300) CARD N0.1 of 1 Reval Year:2009 Tax Year:2013 .885 AC YADKIN VALLEY RD LIFE ESTATE 0.860 AC SRC=Inspection � reised b 02 on 03/12/2007 03001 SPARKS RD 7W-03 C- EX-AT- LAST ACTION 20100922 CONSTRUCTSON DETAIL MARKET VALUE DEPRECIATION CORRELATION OF VALUE Founda[ion-3 Eff. BASE Standard 0.4400 -� ontinuous Footin 5.0 USE MO Area UA RATE RCN EYB AYB REDENCE TO MARKET � ub Floor Sys[em-4 PI wood $p Ol Ol I 762 103 71.07 12747 19651965 %GOOD 56.0 DEFR.BUILDING VALUE-CARD 71 39 Exterior Walls-21 TYPE:Single Family Residential Single Family Residential DEPR.OB/XF VALUE-CARD 810 � Face Brick 34.0 MARKET LAND VAIUE-CARD 32,000 � STORIES:5-Ranch w/basement OTAL MARKET VALUE-CARD 104,20 � Roofing Structure-03 . able 8.0 � -- Roofing Cover-03 � s halt or Com ositlon Shin le 3.0 OTAL APPRAISED VALUE-CARD 104,200 � � nterior Wall Cons[ruttion-5 � OTAL APPRAISED VAWE-PARCEL 304,20 D wall/Sheetrock 20.0 nterior Floar Cover-14 OTAL PRESENT USE VALUE-PARCEL 0 . a et � 6.0 OTAL VALUE DEFERRED-PARCEL 0 Heating Fuel-02 OTAL TAXABIE VALUE-PARCEL 104,200 � il WoodorCoal 0.0 +--------41---------+ Heating Type-04 � I U B M +--1 4--+ PRSOR Forced Air-Ducted 4.0 I I U C V I BUILDING VALUE 66,000 ir Condi[ioning Type-03 2 I I BXF VALUE entral 4.0 5 Z Z LAND VALUE - 29,29 8edrooms/Bathrooms/Half-Bathrooms I 0 0 PRESENT USE VALUE 0 � ' 1/1/1 6.00 I � I I DEFERRED VALUE 0 � Bedrooms I I I OTAL VAWE 95 29 � � BAS-IFUS-OLL-O � +--------41---------+--14--+ Bathrooms � BAS-1 FUS-0 LL-0 Half-Ba[hrooms � +---2 0----+ BAS-1 FUS-0 LL-0 I I PERMIT OTALPOINT VALUE 8.00 I I CODE DATE NOTE NUMBER AMOUNT BUILDING ADJUSTMENTS I I = . 2 2 uali 3 AVG 1.000 2 2 ROUT:WTRSHD: ha e Desi n 4 FACTOR 4 1.0500 I I SALES DATA ize 3 Size 1.0000 I I FF. INDICATE � +-10-+ +-11-+ OTAL AD]USTMENT FACTOR 1.05 5 B A S I RECORD DATE DEED SALES OTAL QUALITY INDE% 103 +-1 0-+ � I BOOK PAGE M R TYPE / / PRICE ; I U E P I I 0352 177 11 200 GD U I " 1 1 I 0 0 2 +-10-+ 5 I I 1 I HEATED AREA 1,465 0 I NOTES +'--'-"'ql'------"+ SUBAREA UNIT ORIG% ANN DEP °h OB/XF DEPR. TVPE GS AREA ^/o RPL CS ODE DESCRIPTIONLTH HUNIT CRICE COND BLDG#L/B AYB EYB RATE V COND VALUE 8A5 1 465 10 104118 1 TORAGE 1 1 19 15.0 30 _ L 197 1985 53 2 806 UBM 1,025 02 1456 Z4 HED 6 1 96 5.1 30 _ L 19811985 SS 0 CP 28 O15 2985 OTAL OB/XF VALUE� 80 UEP 10 OS 355 FIREPLACE 3-1 Story 2 25 � . ' Sin le UBAREA 2,87 127,47 OTALS BUILDING DIMENSIONS BA5=W11N22W20522W1055 UEP=W10510EION10$520E41N25$PTR=N30UBM=N2 UCP=E34N20W14S20$N23W41525E41$530$. LANDINFORMATION HIGHEST THER AD]USTMENTS TOTAL ND BEST USE LOCAL FRON DEPTH/ LND COND ND NOTES ROA LAND UNIT LAND UNT TOTAL AD]USTED LAND LAND SE CODE ZONING TAGE DEGTH SI2E MOD FACT RF AC LC TO OT TVPE PRICE UNITS TVP AD]5T UNIT PRICE VALUE NOTES . RURALAC 0120 277 0 2.5680 4 1.2000 +10+10+00+00+00 PW II 800.0 0.88 AC 3.082 36 367.6 32003 OTAL MARKET LAND DATA 0.88 32,00 OTAL PRESENT USE DATA �� 1 � �`l � � � � �, ��:� � e �U 5 � ? � lh �� C � . http://maps.co.davie.nc.us/ITSNet/AppraisalCard.aspx?parce1=C600000118 1/9/2013 „ r. -•i�� {�•. r... . ..;.5�: ..�._., ,.�o�-.a._' � w� , �-t. , � - „ r.,-. � .-- . , ,. -, . � - . - i .- � .. s r . , : . �., -�.-.:< . ... ,�r.,_”- ' e,•��.:,.:.�.:�.,.� :.,.. . .�.; �``.5.. .. .,.�. .�.r � 'AU�i`HORIZAT�ION?:o, ,� ,� � �j� DAVIE COUNTY HEALTH DEPARTMENT �� 6 "�S G / ' : Environmental Health Section PROPERTY INFORMATION „Permittee`� � � P.O. Box 848 Name:�� S� �� L/�,�_. :, Mocksville,NC 27028 Subdivision Name: / �� Phone# 336-751-8760 ,� , ' Directions'to property: � � ! I ,� ,�`Y`..� Section: Lot: %�j� � /�� ' AU`HORIEWAT�ER�R �� (!- _'�� ''"/�/SYSTEM CONSTRUCTION Tax Office PIN:# - J .�.�?��/.:��,l'.. Road Name: Zip: **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmentai Health Section prior to issuance of any Building Permits.This Forn�/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (ln compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) �_, ' ,1 ] � ,�' I/' ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION C,��,�%��,%'�,f�` '" i:L,/' C��i:'�i �,�%p`1'� IS VALID FOR A PERIOD OF FIVE YEARS. �`- EN RONMENTAL HEALTH SPECIALIST DATE ISSUED }. � .� k '� . �..;"�� r �t . ` .. . � . . . , _ � ;,- . ' . � ' .. . . . . , � ' , .. � �� "/ S- G / �� -- � i � ;- ;� . ,,� � �' �,;� DAVIE COUNTY HEALTH DEPARTMENT �:: . __� - ;' � `�;�,`�� _ TMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION _ Permi[te��'s�-----� F �..,� � f ��Name,. ��!��,��'�.��'? 'r=-��"�-fJ�� Subdivision Name: � _ Directions to ro ert : /�� fr�"'"`%"-•{� �'� p p y � Section: Lot: . ,` ,,f t� /', ; Il17PROVEMENT ., r ,�', , 0�;;. �;,��,f� PERMIT Tax Office PIN:# - - . ,�" .J � Road Name: Zip: **NOTE**This Improvement Permit DOFS NOT authorize the construction or installation of a septic tank system or any wastewater system.An ALTTHORIZAT'ION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building pemut (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 , ,, ,�.";,',_. , �` .. : ,� ';• ". ;.•%� ,%/ PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THI.S PERIVIIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFTCATION:BUILDING TYPE #BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLFISHIFT #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 ROCK DEPTH LINEAR Ff. ,�/ �-- " � OTHER S�� v�l�/ ��f[//l REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENTPERMITLAYOUT �q��}�pV�D EFFLU�t�T FILTEI2� �RI�Ef�tS) IF� 6" II�LO.! FItdTS.�LU GRRi�� J6�� /�//w � **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 830-930 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(7b'd'}��$�8�/dbh�' (336)751—�7L�a OPERATION PERMIT SYSTEM INSTALLED BY: �� a�s r� � � �" �,� /� �.. AUTHORIZATION NO.��'OPERATION PERMIT BY: �/�" DATE: l!/ � � �i **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL YN NO WAY BE TAKEN AS A. GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD OSN6(Revised) _ ,. I � - � ' �'' . j . . . .' ��. . ,r' . . . , . . �,� , ' .,.. f� •�.^ '� . '4� ��r� . aV�� ` � �`•'� �"'' � �+ " ' DAVIE COUNTY HEALTH DEPARTMENT ', �;, � '�., . � � Y��Y' '' _ Environmental Health Section —? �k` "y- ; PO Box 848/210 Hospital Street � � Mocksville,NC 27028 Phone: (336)751-8760 r ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) REPLACEMENT❑ REMODELING o RECONNECTION ❑ Name: ��/�l E.I �'• /3c w��J Phone Number: ��" G �� (Home) . Mailing Address: �� /l%,=%�� U�i�� i�� (Work) �/!;;`,,: r? lu o f9 Detailed Directions To Site: Property Address: Please Fill In The Following Information About The Existing Dwelling: � Name System Installed Under:"�/�%�r4.'� la�wr�- Type Of Dwelling: ��1'f�-- Date System Installed(Month/Day/Year): /%«� ? Number Of Bedrooms: � Number Of People: �- Is The Dwelling Currently Vacant? Yes❑ No+e-'' If Yes,For How Long? Any Known Problems?Yes❑ No�"'"If Yes,Explain: Please Fill In The Following Information About The New Dwelling. ` �, Type Of Dwelling: ��f[� Number Of Bedrooms: Number Of People: . i . � � � .�'� +',.-r✓ � � � � Date Requested: !� '�� , Requested By. fit.� (S� ature) l � For Environmental Healfh Office Use Only Approved�Disapproved ❑ � `�� / � Comments��7 fUs•'�iS%t� - U •�� lff� ,/l,.-�` r-�`~.fv�� .�� r''�� lo//-�d' �J.t... �r`�, i�/�. .Lc�.:,� - i/.�� dC.. ,Q,.�L h� A1a--./� � i � �: Environmental Health Specialist� �� ,�t Date �"�-�U� � *The signing of this form by the$nvironmental 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: f�� Account #: !` Invoice #: / � f s r / % f ' '' �� DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION '� APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) q ' �--� NAME � `z-/'�-e -S �O�;. � LnS PHONE NUMBER �� (� ADDRESS �� n� �- Y SUBDIVISION NAME � � � / t-� /�-�" LOT # DIRECTIONS TO SITE � � DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING � � � � DATE REQUESTED � v INFORMATION TAKEN BY Thia is to certify that the information provided is correct to the best of my knowledge,and that I understand I am responsible}or all charges incurred irom this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev.1/93 . �r � ( � /T�