The URL can be used to link to this page

125 East Rolling Meadow Road Lot 21Davie County, NC Tax Parcel Report Wednesday. December 21. 2016 Parcel Number: NCPIN Number: Account Number: Listed Owner 1: Mailing Address 1: City: State: Zip Code: Legal Description: Assessed Acreage: Deed Date: Deed Book / Page: Plat Book: Plat Page: Building Value: Land Value: Total Assessed Value: WARNING: THIS IS NOT A SURVEY Parcel Information H9080A0021 Township: Shady Grove 5789635399 Municipality: 82518135 Census Tract: 37059-804 VOREH MATTHEW WADE Voting Precinct: EAST SHADY GROVE 125 E ROLLING MEADOW RD Planning Jurisdiction: Davie County ADVANCE Zoning Class: DAVIE COUNTY R -A NC Zoning Overlay: 27006-7562 Voluntary Ag. District: No LOT 21 FALLINGCREEK FARM PHASE I Fire Response District: ADVANCE 0.71 Elementary School Zone: SHADY GROVE 1/2002 Middle School Zone: WILLIAM ELLIS 004040579 Soil Types: PcB2 0007 Flood Zone: 049 Watershed Overlay: DAVIE COUNTY Outbuilding & Extra Freatures Value: Total Market Value: 161 �T All data is provided as Is without warranty or guarantee of any Idnd either expressed or implied Including but not limited to the Davie County, implied warranties of merchantability or f iness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims orcauses of action due to l� C or arising out of the use or inability to use the GIS data provided by this website. Vf.- DAVIE �OUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY: INFORMATION Narhi.. (' : c Subdivision' Name: f''f Directions to "property: i..' SectionLot: v%{ IMPROVEMENT PERMIT Tax Office PIN:# Road Name"r/Zip: **NOTE** This Improvement Permit DOES NOT authorize the construction or installation of aseptic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTIONmust 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*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE ,'''% PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL: HEALTH PECIALIST BATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE' : INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS'�_ # BATHS �_ # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT / # SEATS /INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY_ DESIGN WASTEWATER FLOW (GPD) (a NEW SITE v REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE iA=GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH_ LINEAR FT �� OTHER ,REQUIRED SITE MODIFICATIONS/CONDITIONS: **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. DCHD 05196 (Revised) .77 .w, •qr'� -r, „ .. , :... _ ... � .. Fly - 7. DAVIE OUNTY HEALTH DEPARTMENT '=� IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION :.:� Name'.' t .+'z,., •f"."'"' Subdivision Name. ` f Directions to property:. r° Section: s Lot: IMPROVEMENT PERMIT Tax Office PIN:# "' - , - Road Name Zip: **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*** 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 THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS�r # BATHS V # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY ( ) DESIGN WASTEWATER FLOW (GPD) G U NEW SITE 1.�~ ,REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZEe&LGAL. PUMP TANK ` GAL. TRENCH WIDTH -' ` ) ROCKEPTH - LINEAR FT, OTHER .:Ile REQUIRED SITE MODIFICATIONS/CONDITIONS: s , 'IMPROVEMENT PERMIT LAYOUT *APPRGVEII EFFLUENT FILTER* *RISER(() IP 61' REM FINISHED GRADE* N :t 5th. y.a. -A AUTHORIZATION NO. OPERATION PERMIT BY: DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WA' GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 05/96 (Revised) • i , t- I APPUCAMON FOR SIZE EVAUJAMON/IMPROVEMENT PERMIT & AT Davie County Health Department 4 1999 Ct Environmental Ifealtfi Section // ` P.O. Box 818/210 Hospital street ENVIRONMENT n� 1 Mockoville , NC 27028 DAVIE COULH HEq(I NTI �\ (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Nash to be Billed G contact Person Mailing Address � �b A'-� 1 k—ag' -Of > Bow phone G[LJ�n to gj-2 ' City/State/ZIP -X--Y—,-�7 G-Lya Business Phone -( 40 —'�! 4-7 2. Name on Permit/ATC if Different than Above Mailing Address City/state/Zip 3. Application For: U Site Evaluation K Improvement Permit/ATC ❑ Both 4. system to service: 9 House ❑ Mobile Home 0 Business ❑ Industry ❑ Other s. If Residence: # People # Bedrooms , 5 # Bathrooms 7— Dishwasher q garbage Disposal washing Machine 0 Basement/Plumbing 0 Basement/No Plumbing 6. If Business/Industry/other: Specify type # Commodes # Showers # Urinals # people # Sims # dater Coolers IF FOODSERVICE: 11 Seats Estimated Nater Usage (gallons per day) 7. Type of water supply: County/City ❑ Well V ❑ Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes t No If yes, what type? ***I11fP0RTANP** CLIENTS MUST COMPLET'ETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUSTRESUBMITTED by the client with THIS APPLICATION. Property Dimensions: �D �f- V -,,G f, q i 4- Z 39 WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # '59f�5 6 -3$?Q 3 fl0 Property Address: ?[toad Name City/Zip r106 If in a Subdivision provide Information, as follows: Name: fiuI .ctyv- ( e— Section: i Block: Lot: V_ Date Propcay Flagged: �! This is to certify that the information provided is correct to the best or 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 ant responsiblefor all ayarges 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 ' to conduct all testing p educes as necessary to determine the site sui ilih DATE SIGNATURE K( 61� 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). Revised DCHD (07/98) Account No. .3 / Invoice No. 61 - APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT T TM Davie County Health Department Environmental Health Section q '" P O. Box 848 AUG -- 6 1�' 97 Mocksville, NC 27028 (704)634-8760 ****IMPORTANT**** IMPORTANT THIS APPLICATION CANNOT BE PROCESSED, ALL THE REQUIRED INFORMATION IS PROVIDED. 1 / / G'v►9 1. Name to be Billed W 4s�y %c uJ beyPx Contact Person Mailing Address e2tS sr�t�� Sth a I rGrd! Home Phone City/State/Zip � ,vs Jap n/ _.5i4, ., A( e • r;1719 3 Business Phone 9 9 � " d 6 7 .2 99�-alio 2. Name on Permit/ATC if Different than Above Sao m Mailing Address City/State/Zip 3. f :,plication For: C-1' Site Evaluation ❑ Improvement Permit & ATC ❑ Both 4. S --stern to Serve: ❑ House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other--.-.,. 5. If Residence: # People # Bedrooms # Bathrooms ❑ Dishwasher ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing v 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 ❑ Well Q Community 8. Do you anticipate additions or expansions of the facility this systemis intended to serve? .01 Yes J3 No If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: q9, ( 74 %tt'e_s 1 WRITE DIRECTIONS (from Tax Office PIN: # �5 7 g l - 63 - J 7 o 3 Mocksville) TO PROPERTY: Prol erty Address: Road Name G C- - L I / City/Zip Ajygwd!' _ A& If in Subdivision provide information, as follows: CAI Name: Section y Lot # 'a� 1 1 i 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 County and owned by t0 < - to conduct all testing procedures b }` as necessary to determine the site suitability. �f 1 DATE g —% c1 2 SIGNATURE f Revised DCHD (06-96) ^L g'tC l Y • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION ✓ LOT, 4` Soil/Site Evaluation Al ' So'Yt ecv APPLICANT'S NAME � PROPOSED FACILITY .% SUBDIVISION Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit DATE EVALUATED PROPERTY SIZE /��'�� AG' ROAD NAME k1 'Q�Ih l / Public v Cut FACTORS 1 2 3 4 5 6 7 Landscape position ,C L Slope % .2 HORIZON I DEPTH Texture group Consistence Structure Mineralogy/ HORIZON II DEPTH 3•( Texture group Consistence r / Structure 5 /c Mineralogy 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: LONG-TERM ACCEPTANCE RATE: REMARKS: '.-S '( f e DCHD (01-90) EVALUATION BY: ^%1 11 Z OTHER(S) PRESENT: 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 " C40NSTRUCTION For office use Only . AUTHORIZATION •CDP Fite Number 121561-1 °"- Davie County Health Department tY P County ID Number. H9-080-Ao-021 f' 210 Hospital Street Evaluated For: REPAIR P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax: 336-753.1680 0 / 3 / 2 ? 3 Applicant: Matthew and Samantha Voreh Property Owner: Matthew and Samantha Voreh Address: 125 E Rollingmeadow Drive Address: 125 E Rollingmeadow Drive City: Advance City: Advance State2ip: NC 27006 State2ip: NC 27006 Phone it: Phone #: Property Location & Site Information Address/Road #: Subdivision: FallingCreek Phase: Lot: 21 125 E Rollingmeadow Drive Advance NC 27006 Directions Structure: SINGLE FAMILY Hwy 64 East. left on to Hwy 801 going north, right onto Peoples Creek Rd. at the church. Fallingcreek on left then # of Bedrooms: 3 1st right. # of People: � 'Water Supply: PUBLIC System Specifications Minimum Trench Depth: a 4 rSiteClassification: Ps tnches Minimum Soil Cover.ystem? OYes QNo Inches Design Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 . 3 Maximum Soil Cover: Inches 'System Classification/Description: `Distribution Type: GRAVITY- PARALLEL (eq. d -box) TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) S'. T k' 'Proposed System: 25% REDUCTION Nitrification Field Sq. ft. No. Drain Lines eptic an . Gallons 1 -Piece: OYes QNo Pump Required: OYes ONo OMay Be Required Pump Tank: Gallons 1 -Piece: OYes ONo Total Trench Length: 3 0 0 ft GPM—vs—ft. TDH Trench Spacing: _ 9 Onches O.C. Feet O.C. Dosing Volume: _ Gallons Trench Width: _ 3 6 Qlnches Feet Grease Trap: Gallons Aggregate Depth: inches Pre -Treatment: ONSF OTS -1 OTS -II Septic Tank Installer Grade Level Required: 01 011 OIII OIV Pagel of 3 `CDP File Number 121561 -1 *Site Classification: Design Flow: Soil Application Rate: *System Classification/Description: *Proposed System: County ID Number: H9 -080 -AO -021 uired:OYes ONo ONo, but has Available Nitrification Field Sq. ft. No. Drain Lines Total Trench Length: ft. ❑ Open Pump System Sheet Trench Spacing: — 0Inches 0. O Feet O.C. Trench Width: Inches Feet Aggregate Depth: inches Minimum Trench Depth: Inches Minimum Soil Cover. Inches Maximum Trench Depth: Inches Maximum Soil Cover: Inches *Distribution Type: Pump Required: Oyes ONo OMay Be Required Pre -Treatment: ONSF OTS -1 OTS -II - "Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. *Permit Conditions The issuance of this permit bythe Health Department in no wayguarantees the issuance of other permits. The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. This Authorization for Wastewater System Constriction shall be valid for a penton equal to the period of validity of the Improvement Permit not to exceed five years, and maybe issued at the sametime the Improvement Permit Issued (NCaS 130A -336(b)} If the Installation has not been completed during the period of validity of the Construction Permit, the information submitted In the application for a permit or Construction Authorization Is found to have been Incorrect falsified or changed. or the site Is altered, the pernit or Construction Authorteation shall become Invalid, and maybe suspended or revoked (.1937(g)). The person owning or controlling the system shall be responsible for assuring compliance with the laws, rules, and permit conditions regarding systen location, Installation, operation, maintenance, monitoring, reporting and repair (1938(b)). Applicant/Legal Reps. Signature Required? OYes ONo Applicant/Legal Reps. Signature- Date. *Issued By: 2244 - Daywalt. Andrew Date of Issue: 0 5 / 1 3 / a 0 1 3 Authorized State Agent: 0,U/,Q,(1aV t/Zi,V00 Malfunction Log OYeS OHbrhd Drawing Olmport Drawing Total Time:(H HV M) **Site Plan/Drawing attached.** Page 2 of 3 0 1 Hours 0 0 It mutes S-10 - CA'S issued - repair - CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number: 121561 -1 210 Hospital Street H9 -080 -AO -021 P.O. Box 848 County File Number: Mocksville NC 27028 Date: 0 5/ 1 3/ 0 1 3 Olnch Drawing Drawing Type: Construction Authorization Scale:. . . OBlock ft. ON/A Davie County, NC - GoMaps Advanced Page 1 of 1 241 c N rb/ http://maps2.roktech.net/davie_gomaps/index.html 5/13/2013 f ... yj i'. RC�*d S{} 2`- I ■�I�I�lflfll0��lf1��.y 3� I f ;i '181 �� 97 124 137 -------------- 21 116 -n a l ; r X176 � o G) :gym rmn �I� N cU i - X135 ..> J25 t - a (D '116611 f 1 I~ ----- I I - .. 4B �j i I I I ROLLING%VEA69W f D r... 40 m� nor rtrAPliiA RD --'—' �. •^ � � vii 111161- u r �� n.—. — _ = — �---"'_ i I I I ' f - i Latitude; 350 55' 21.00" Longitude, -800 23' 49,41" 241 c N rb/ http://maps2.roktech.net/davie_gomaps/index.html 5/13/2013 r 4ccount #: 990002057 Billed To: Matthew Voreh ince Name: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PINIEH #: 5789-73-5399 Subdivision Info: Palling Creek 1 Lot # 21 Location/Address: Rolling Meadow Road -27006 Property Size: see map I; rC Number: 3015 t AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION TE** 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 WASTE WATE NSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. •onmental Health Specialist's Signature: - Date: CERTIFICATE OF COMPLETION DTE** The issuance of this Certifica of Com letic has been installed in complian a with icle Disposal Systems," but shall in NO WA be given period of time. = N ti� X J r q t,t,�, a5 Septic System Installed By: avironmental Health Specialist's Signature : _HD 05/99 (Revised) shall indicate the system described on Improvement/Operation Permit 1 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and ken as a guarantee that the system will function satisfactorily fo"r any 0 T Date: J/• 3L, DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section P. O. Boz 848/210 Hospital Street - - Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002057 Tax PIN/EH #: 5789-73-5399 Billed To: Matthew Voreh Subdivision Info: Falling Creek 1 Lot # 21 Reference Name: Location/Address: Rolling Meadow Road -27006 Proposed Facility: Residence Property Size: see map ATC Number: 3015 **NOTE** This Improvement/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 T1 #People #Bedrooms Sf #Baths Dishwasher- Garbage Disposal: ❑ Washing Machin 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) S&O Site: New;1"Repair ❑ System Specifications: Tank Size,&�> GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench WidthcFw/ Rock Depth ja„ Linear Ft,: - IMPROVEMENT/OPERATION PERMIT LAYOUT - AV Z14QVED EFFLUENT FILTER RISERS) IF 6 "BELOW FINISHED GRADE. ****NOTICE: Contact a representatia 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. t ke day of installation. Telephone # is (336)751-8760.**** 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 M 990002057 Tax PIN/EH M 5789-73-5399 Billed To: Matthew Voreh Subdivision Info: Palling Creek 1 Lot # 21 Reference Name: Location/Address: Rolling Meadow Road -27006 Size: see ATC Number: 3015 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 WASTE WATE NSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. // �,Tfe-'�! Environmental Health Specialist's Signature: - Date: �' w 49 CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certifica of Com let has been installed in complian a with is Disposal Systems," but shall in NO WA 1: given period of time. ` N X q r _x 0 -T6pjt lk� l -9 Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) shall indicate the system described on Improvement/Operation Permit 1 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and ken as a guarantee that the system will function satisfactorily for any Date: FOR SITE EVAU ATION/IMPROVEMENT PERMIT & ATC Davie County Health Department �� Envirnnmenta/Health Section NOV 2 $ X631 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 FNviRONN ENTAL HEALTH I (336) 751-8760 **WIMPMTANT***__THIS-APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED I INFORMATION IS PROVIDED. Reefer to the INMRMATION BULLETIN foyyr//�� instructions. 1. Nsme to be Bailed Int .e'J �?�aP Ub (ZP.� Contact Person ,'1e�ili�rt�e%0 4�.�)P, Mailing Address wit be-�A000 =64 Rome Phone City/stab/ZIp - -Ci V A.n) �P _ / fl Business phone 2. Name on Permit/ATC if Different than Above )sailing Address City/stab/Zip 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC �th 4. system to service: O'iiouse 0 Mobile Home 0 Business 0 Industry 0 Other s. If *Residence: f People _ # Bedrooms i Bathrooms Z .B'Dishvasher n Garbage Disposal fllashing Machine O Basement/Plumbing O Basement/No Plumbing 6. If Business/Industry/Other: specify type # Commodes # Shovers # People # sinks # Urinals # Water Coolers IS FOODSERVICE: # Seats _/ Estimated Water Usage (gallons per day) 7. Type of Mater supply: iounty/City ❑ Well 0 Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? O Yes O No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensiods: �isx3�1 �C l 7i( o� y� WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # �S S3 1� w� �� Sovm. Property Address: Road Name V�O�� Lt✓ � � I��o�� o e � �tl±zto City/zip y cr If In a Subdivision provide Information, as follows: � o Lw l be o PxO) o P"'e Name: tt C eC1.5, 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 front 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 \ i e AAc o ie,..l > . to conduct all testing procedures as necessary to determine the site suitability. DATE SIGNATURE L2 THIS AREA MAY BE USED FOR DRAWING YOUR STM PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge J Date(s): I Client Notification Date: I EHS: Revised DCHD (07/99) Account No. O 5 Invoice No. UP 14' T v s• :: tet,,.:,.: i- -.s^r. v_..". AUTHORIZA'rl.ON NO -,,A DAVIE COUNTY HEALTH; DEPARTMENT „ - Environmental Health Section' PROPERTY INFORMATION Permittee's P.O. Box 848 "�41 Natt�e: - �' !�/ ��` C Mocksville, NC 27028 Subdivision Name: Phone # 336-751-8760 ,/ Lot: Section: Directions to property: ��' � =!" /r'r`'rr 1 AUTHORIZATION FOR _ WASTEWATER' Tax Office.PlN:# - --o SYSTEM CONSTRUCTION , Road Name: ;/ior V/Zip: **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Rermits. This Fomi/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article l l of G.S. Chapter -130A. Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) %l ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION, e IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED