150 Brier Creek Road Lot 8Davie County, NC Tax Parcel Report Friday, December 30, 2016
5 �y 120
128
�
144
_=138 '
150
4
170.
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125
7-1
WARNING: THIS IS NOT A SURVEY
Parcel Information
Parcel Number: H703OA0040 Township: Shady Grove
NCPIN Number: 5779072510 Municipality:
Account Number: 54122590 Census Tract: 37059-804
Listed Owner 1: NIFONG JAMES FRANKLIN Voting Precinct: WEST SHADY GROVE
Mailing Address 1: 150 BRIER CREEK ROAD Planning Jurisdiction: Davie County
City: ADVANCE Zoning Class: DAVIE COUNTY R -A
State:
Zip Code:
Legal Description:
Assessed Acreage:
Deed Date:
Deed Book / Page:
Plat Book:
Plat Page:
Building Value:
Land Value:
Total Assessed Value:
NC Zoning Overlay:
27006-0000 Voluntary Ag. District:
LOT 8 GREEN BRIER ACRES Fire Response District:
0.63 Elementary School Zone:
1/1900 Middle School Zone:
001280335 Soil Types:
0004 Flood Zone:
172 Watershed Overlay:
Outbuilding 8r Extra
Freatures Value:
Total Market Value:
No
ADVANCE
SHADY GROVE
WILLIAM ELLIS
EnB
DAVIE COUNTY
9�
Davie County,
All data is provided as is without warranty or guarantee of any Idnd either expressed or Implied Including but not limited to the
Implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the
NC
County of Davie, North Carolina, Its agents, consultants, contractors or employees from any and all claims or causes of action due to
GIS data by this
or arising out of the use or Inability to use the provided website.
Applicant: Frank Nifong
Address: 150 Brier Creek Rd
City.. Advance
State20: NC 27006
Phone _: (336) 408-0576
Address/Road _:
150 Brier Creek Rd
Advance NC 27006
Structure: SINGLE FAMILY
of Bedrooms:
z of People:
'Water Supply: PUBLIC
'IP Issued by: 2244 - Daywalt, Andrew
'CA issued by: 2244 - Daywalt, Andrev.
Design Flow: 3 6 0
Soil Application Rate: 0 2 5
Nitrification Field
No. Drain Lines
Total Trench Length
Trench Spacing:
Trench Width:
Aggregate Depth:
'CDP File Number 121832-1
H7.030•AO.040
County ID Number.
Evaluated For: REPAIR
Township'.
Property owner: Frank Nifong
Address: 150 Brier Creek Rd
City: Advance
State2ip: NC
Phone::: (336) 408-0576
27006
erty Location & Site Information
SubdPAsion: Green Brier Acres Phase: Lot: 8
Directions
Hwy 64 E, left on Fork Biby Rd, road on left past
Bailey's Chapel on right.
'System Classification/Description:
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
Saprolite System? OYes ONo
'Distribution Type: GRAVITY -SERIAL Pump Required?
Yes (:J10
'Pre -Treatment:
Drain field
Sq. It
2 8 4 ft.
()Inches O.C.
`)Feet O.C.
8 Inches
Feet
Inches
Minimum Trench Depth:
Inches
'System Type, INFILTRATOR OUICK 4 STANDARD
Installer: frank Iransou
Certification :::
'EHS: 2244 - Daywart, Andru.v
Date: 0 9/ 1 2/ 2 0 1 3
Minimum Soil Cover. Inches Approval Status
Maximum Trench Depth: Inches p Approved ❑ Disapproved
ximum Soil Cover: Inches
OPERATION PERMIT
- �: •�
Davie County Health Department
? f 1 `s
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Frank Nifong
Address: 150 Brier Creek Rd
City.. Advance
State20: NC 27006
Phone _: (336) 408-0576
Address/Road _:
150 Brier Creek Rd
Advance NC 27006
Structure: SINGLE FAMILY
of Bedrooms:
z of People:
'Water Supply: PUBLIC
'IP Issued by: 2244 - Daywalt, Andrew
'CA issued by: 2244 - Daywalt, Andrev.
Design Flow: 3 6 0
Soil Application Rate: 0 2 5
Nitrification Field
No. Drain Lines
Total Trench Length
Trench Spacing:
Trench Width:
Aggregate Depth:
'CDP File Number 121832-1
H7.030•AO.040
County ID Number.
Evaluated For: REPAIR
Township'.
Property owner: Frank Nifong
Address: 150 Brier Creek Rd
City: Advance
State2ip: NC
Phone::: (336) 408-0576
27006
erty Location & Site Information
SubdPAsion: Green Brier Acres Phase: Lot: 8
Directions
Hwy 64 E, left on Fork Biby Rd, road on left past
Bailey's Chapel on right.
'System Classification/Description:
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
Saprolite System? OYes ONo
'Distribution Type: GRAVITY -SERIAL Pump Required?
Yes (:J10
'Pre -Treatment:
Drain field
Sq. It
2 8 4 ft.
()Inches O.C.
`)Feet O.C.
8 Inches
Feet
Inches
Minimum Trench Depth:
Inches
'System Type, INFILTRATOR OUICK 4 STANDARD
Installer: frank Iransou
Certification :::
'EHS: 2244 - Daywart, Andru.v
Date: 0 9/ 1 2/ 2 0 1 3
Minimum Soil Cover. Inches Approval Status
Maximum Trench Depth: Inches p Approved ❑ Disapproved
ximum Soil Cover: Inches
CDP File Number 121832-1 County ID Number: "7-030-Ao-040
Manufacturer: existing
STB:
Gallons:
Date:
QuptlI: rarnc
Lat.
Long:
Installer:
I I Certification #:
'EHS:
'Filter Brand:
ST Marker: ❑ Yes ❑ No
Reinforced Tank: ❑ Yes ❑ No
1 Piece Tank: ❑ Yes ❑ No
Date:
Approval Status
❑ Approved ❑ Disapproved
Pump Tank
Manufacturer. Installer.
PT:
Gallons:
Date:
Dosing Volume:
Riser Sealed ❑
Yes
Riser Height: ❑
Yes
einforced Tank: ❑
Yes
1 Piece Tank: ❑
Yes
rA
❑ No
❑ No (Mm. 6 in.)
❑ No
❑ No
% Pipe Size: inch diameter
Pipe Length: feet
'Schedule:
Pressure Rated ❑ Yes ❑ No
Approved fittings ❑ Yes ❑ No
Certification
'ENS:
Date:
Approval Status
❑ Approved ❑ Disapproved
_j
upply Line
Installer:
Certification ::
'ENS:
Date: /
Approval Status
❑ Approved ❑ Disapproved
Pump Type:
Installer:
Dosing Volume:
—
Gal Certification :
Dram Down".
Inches
'EHS:
'Chain:
Date.
Valves Accessible
❑ Yes
❑
No
Flow Adjustment Valve
❑ Yes
❑
No
Check -valve
❑ Yes
❑
No
Approval Status
PVC unions
❑ Yes
❑
No
❑ Approved ❑ Disapproved
Vent Hole
❑ Yes
❑
No
\ Anti -siphon Hole
❑ Yes
❑
No
CDP File Number 121832-1
County ID Number: HMM-A0-0:0
Alarm Audible ❑ Yes
Alarm Visible ❑ Yes
"Operation Permit completed by.
Authorized State Agent:
Approval Status
El No
El No ❑ Approved ❑ Disapproved
2244 - Daywal;. Andrew
Date of Issue: 0 9/ 1 2/ 2 0 1 3
This system has been installed in compl,ance with applicable FJC General Statutes: Article 11, Chapter 130A, Rules for
Sewage Treatment and Disposal, 15A NCAC 18A.1900 et. Seq., and all conditions of the Improvement Permit and
Construction Authorization. This property is served by a TYPE II A. sewage septic system.
Rule .1961 requires that a Type TYPE u A_____ septic system meet the following criteria.
1.1inimurt Systern Review By The Local Health Department: N'A____T__—_—__
Llanagement Entity: 0_ti'NER_
Minimum System Inspection 11aintenance Frequency By Certified Operator:
NIA
Reporting Frequency By Certified Operator: N'A
Rule .1961 requires that a Type IV and V septic systems designed fora horme'business owner must maintain a valid contract
with a public management entitywrth a certified operator or a private certified operator forthe life of the septic system.'
Rule .1961 requires that Type VI septic systems designed fora home business owner must maintain a valid contract with a
public management entity with a certified operator for the life of the septic system.
Rule. 1961 (2) (e) requires a contract shall be executed between the system owner and a management entity prior to the
issuance of an Operation Permit for a system required to be maintained bya public or private management entity, unless the
system owner and certified operator are the same. The contract shall require specific requirements for maintenance and
operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long as the
system is in use, and other requirements for the continued proper performance of the system. It shall also be a condition of
the Operation Permit that subsequent owners of the systems execute such a contract.
t =)Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Activity Code: S-19 2AB - OP issued NEW Type 11 ADS B odirruser
Total TimeJHH.MM)
0 1 Hours 3 0 Minuies
crectrlc r-qulpment
r
NEf.1A 4X Box or Equivalent
❑
Yes
❑
NO
Installer:
Box 12 inches Above Grade
❑
Yes
❑
No
Certification:::
Box Adj. To Pump Tank
❑
Yes
❑
No
Conduit Sealed
❑
Yes
❑
No
'EFIS_
Pump 1`0anualty Operable
❑
Yes
❑
NO
'Activation Llethod:
Date:
Alarm Audible ❑ Yes
Alarm Visible ❑ Yes
"Operation Permit completed by.
Authorized State Agent:
Approval Status
El No
El No ❑ Approved ❑ Disapproved
2244 - Daywal;. Andrew
Date of Issue: 0 9/ 1 2/ 2 0 1 3
This system has been installed in compl,ance with applicable FJC General Statutes: Article 11, Chapter 130A, Rules for
Sewage Treatment and Disposal, 15A NCAC 18A.1900 et. Seq., and all conditions of the Improvement Permit and
Construction Authorization. This property is served by a TYPE II A. sewage septic system.
Rule .1961 requires that a Type TYPE u A_____ septic system meet the following criteria.
1.1inimurt Systern Review By The Local Health Department: N'A____T__—_—__
Llanagement Entity: 0_ti'NER_
Minimum System Inspection 11aintenance Frequency By Certified Operator:
NIA
Reporting Frequency By Certified Operator: N'A
Rule .1961 requires that a Type IV and V septic systems designed fora horme'business owner must maintain a valid contract
with a public management entitywrth a certified operator or a private certified operator forthe life of the septic system.'
Rule .1961 requires that Type VI septic systems designed fora home business owner must maintain a valid contract with a
public management entity with a certified operator for the life of the septic system.
Rule. 1961 (2) (e) requires a contract shall be executed between the system owner and a management entity prior to the
issuance of an Operation Permit for a system required to be maintained bya public or private management entity, unless the
system owner and certified operator are the same. The contract shall require specific requirements for maintenance and
operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long as the
system is in use, and other requirements for the continued proper performance of the system. It shall also be a condition of
the Operation Permit that subsequent owners of the systems execute such a contract.
t =)Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Activity Code: S-19 2AB - OP issued NEW Type 11 ADS B odirruser
Total TimeJHH.MM)
0 1 Hours 3 0 Minuies
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Di -awing Drawing Type: Operation Permit
)Oo
CDP File Number: 121832 - 1
County File Number: H7 -030 -AO -040
Date: ! /
Qlnch
Scale: OBlock
ONin
ket&)LWj
ftvs�-
C> l�P.�J Bpm
le
MCI- ( r
LLW
F L14ru
Applicant:
Address:
City:
State/Zip:
Phone #:
CONSTRUCTION
AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
For Office Use Only
*CDP File Number 121832 - 1
County ID Number: H7-030-Ao-040
Evaluated For: REPAIR
,\—Township:
MOCkSVIne NC 27028 PLKMI I VALID UNTIL:
Phone: 336-753-6780 Fax: 336-753-1680 0 io / 0
Frank Nifong Property Owner: Frank Nifong
150 Brier Creek Rd Address: 150 Brier Creek Rd
Advance City: Advance
NC 27006 State/Zip: NC 27006
(336) 408-0576 Phone #: (336) 408-0576
Address/Road #:
150 Brier Creek Rd
Advance NC 27006
Structure: SINGLE FAMILY
# of Bedrooms:
# of People:
'Water Supply: PUBLIC
Subdivision: Green Brier Acres Phase: Lot: 8
Directions
Hwy 64 E, left on Fork Biby Rd, road on left past Bailey's
Chapel on right.
\
Site Classification: Ps Minimum Trench Depth: a 4 Inches
Saprolite System? XYes O No Minimum Soil Cover: Inches
Design Flow: 3 6 0 Maximum Trench Depth: Inches
Soil Application Rate: 0 a 5 Maximum Soil Cover: Inches
"System Classification/Description: 'Distribution Type: GRAVITY - SERIAL
TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) S . T k'
`Proposed System: 25% REDUCTION
Nitrification Field
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Aggregate Depth:
eptic an . Gallons
1 -Piece: OYes ®No
Pump Required: O Yes ®No O May Be Required
Sq. ft. Pump Tank: Gallons
1-Piece:OYes ONo
3 6 0 ft. GPM --vs-- ft. TDH
Inches O.C.
— 9 Feet O.C. Dosing Volume: _ Gallons
3 6Inches
O Feet Grease Trap: Gallons
inches Pre -Treatment: O NSF OTS -I O TS -I I
Septic Tank Installer Grade Level Required: 01011 O III ON
Page 1 of 3
CDP File Number 121832-1
,'Repair System
*Site Classification:
Design Flow:
Soil Application Rate:
*System Classification/Description:
*Proposed System:
Nitrification Field
No. Drain Lines
County ID Number: H7 -030 -AO -040
uired:OYes O No O No, but has Available
Total Trench Length:
ft.
❑ Open Pump System Sheet
Trench Spacing: _ O Inches O.
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
Sq. ft.
*Distribution Type:
Pump Required: OYes O No O May Be Required
Pre -Treatment: O NSF 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 by the Health Department in no way guarantees 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 Construction shall be valid for a person equal to the period of validity of the Improvement Permit, not
to exceed five years, and may be issued at the same time the Improvement Permit issued (NCGS 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 permit or Construction Authorization shall become
invalid, and may be suspended or revoked (A 937(g)). The person owning or controlling the system shall be responsible for assuring compliance
with the laws, rules, and permit conditions regarding system location, installation, operation, maintenance, monitoring, reporting and repair
(1938(b)).
Applicant/Legal Reps. Signature Required? O Yes ®No
Applicant/Legal Reps. Signature, Date:
*Issued By: 2244 - Daywalt, Andrew
Authorized State Agent: f�AJL"
Date of Issue: 0 6 / 0 5 /.2 0 1 3
Malfunction Log ®Yes
9 Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
S-10 - CA's issued - repair
Total Time:(HH:MM)
0 1 Hours 0 0 Minutes
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Construction Authorization
rQ/
w op
CDP File Number: 121832 - 1
County File Number: H7 -030 -AO -040
Date: 06 /05/.2013
O Inch
Scale: O Block
O N/A
Page 3 of 3
P1 P2
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street CDP File Number: 121832 - 1
P.O. Box 848
Count File Number: H7 -030 -AO -040
Mocksville NC 27028 y
Date: A6./ 0 5/ .10 1 3
Click below to import an image from an external location: Drawing Type: Construction Authorization
Page 3 of 3
P1 P2
-
CONSTRUCTION
For office use Only -IN
AUTHORIZATION
Saprolite System? OYes QNo
*CDP File Number 121832-1Davie
y
County Health Department
Maximum Trench Depth: Inches
County ID Number: H7 -030 -AO -040
Soil Application Rate: 0 - 2 5
210 Hospital Street
*System Classifx;ationlDescription:
Evaluated For: REPAIR
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
P.O. Dox 848
J Gallons
Township:
1 -Piece: OYes (Z)No
Mocksville NC
27028
PERMIT VALID UNTIL:
Sq. ft. Pump Tank: Gallons'
Phone: 336-753-6780 Fax: 336-753-1680
0 / 0 b 2 0 l 8
Applicant:
Frank Nifong
Property Owner: Frank Nifong
Address:
150 Brier Creek Rd
Address:
150 Brier Creek Rd
City:
Advance
CRY:
Advance
State2ip:
NC 27006
State2ip:
NC 27006
Phone #:
(336) 408-0576
Phone #:
(336) 408-0576
Property Location & Site Information
(Address/Road #:
150 Brier Creek Rd
Advance NC 27006
Structure: SINGLE FAMILY
# of Bedrooms:
# of People:
*Water Supply: PUBLIC
Subdivision: Green Brier Acres Phase: Lot: 8
Directions
Hwy 64 E, left on Fork Biby Rd, road on left past Baile)(s
Chapel on right.
C
Page 1 of 3
Minimum Trench Depth: 2 4 Inches
Site Classification: PS
Saprolite System? OYes QNo
Minimum Soil Cover.
Inches
Design Flow: 3 6 0
Maximum Trench Depth: Inches
Soil Application Rate: 0 - 2 5
Maximum Soil Cover. Inches
*System Classifx;ationlDescription:
*Distribution Type: GRAVITY - SERIAL
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
J Gallons
*Proposed System: 25% REDUCTION
1 -Piece: OYes (Z)No
Pump Required: OYes ONo OMay Be Required
Nitrification Field
Sq. ft. Pump Tank: Gallons'
No. Drain Lines
1 -Piece: OYes QNo
Total Trench Length: 3 6 0 ft
GPM—vs— ft. TDH
Trench Spacing: _ 9
Inches O.C. Dosing Volume: _ Gallons
8Feet O.C. g
Trench Width:_ 3 6
QInches
Feet Grease Trap: Gallons
Aggregate Depth: inches
Pre -Treatment: ONSF OTS -1 OTS -II
1 Septic Tank Installer Grade Level Required: 01011 OIII OIV
Page 1 of 3
GRP Filb PJumber 121832-l' County ID Number: H7.030 -AO -040
Repair 5
❑ Open Pump System Sheet
ulfea:kjTeb VIVu VIVu, DUI ndb mvdlldule opduu
/Repair System
Trench Spacing:
Inches 0.1
*Site Classification:
— Feet O.C.
Trench Width:
Inches
Design Flow:
_ Feet
Aggregate Depth:
Soil Application Rate:
inches
Minimum Trench Depth:
*System Classification/Description:
Inches
Minimum Soil Cover.
.Inches
Maximum Trench Depth:
'Proposed System:
Inches
Maximum Soil Cover:
Nitrification Field
Inches
Sq. ft.
'Distribution Type:
No. Drain Lines
Total Trench Length:
ft.
Pump Required: QYes 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 way guarantees 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 Construction shall be valid for a person equal to the period of validity of the Improvement Permit; not
to exceed five years, and maybe Issued at the same time the Improvement Permit Issued (NCGS 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 permit or Construction Authorization 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 system 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 6 / 0 5 / 2 0 1 3
Authorized State Agent: "Lk� Malfunction Log QYes
OHand Drawing Olmport Drawing Total Time:(H1-111lt)
**Site Plan/Drawing attached.**
1 Hours 0 0 Minutes
Page 2 of 3
S-10 - CKS issued - repair
CONSTRUCTION AUTHORIZATION 121832-1
• Davie County Health Department CDP File Number:
210 Hospital Street H7-030-AD-040
P.O. Box 848 County File Number:
Mocksville NC 27028 Date: 0 6/ 0 5/ 2 0 1 3
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Latitude: 351 55' 59.26' Longitude: -801 27' 8.68'
6/4/2013
Davie County, NC Tax Parcel Report Friday, December 30, 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:
WARNING: THIS IS NOT A SURVEY
Parcel Information
H7030A0040 Township: Shady Grove
5779072510 Municipality:
54122590 Census Tract: 37059-804
NIFONG JAMES FRANKLIN Voting Precinct: WEST SHADY GROVE
150 BRIER CREEK ROAD Planning Jurisdiction: Davie County
ADVANCE Zoning Class: DAVIE COUNTY R -A
NC Zoning Overlay:
27006-0000 Voluntary Ag. District:
LOT 8 GREEN BRIER ACRES Fire Response District:
Land Value:
Total Assessed Value:
0.63 Elementary School Zone:
1/1900 Middle School Zone:
001280335 Soil Types:
0004 Flood Zone:
172 Watershed Overlay:
Outbuilding & Extra
Freatures Value:
Total Market Value:
ADVANCE
SHADY GROVE
WILLIAM ELLIS
EnB
DAVIE COUNTY
No
Daie County, v
p
NCor
All data is provided as is without warranty or guarantee of any Idnd either expressed or Implied Including but not limited to the
Implied warranties of merchantability or fitness for a particular use. Ail 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 or causes of action due to
arising out of the use or inability to use the GIS data provided by this website. _
DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorvti Sewage,,Disposal System - G.S. Chapter 130-A tile13C)
OWNER OR CONTRACTOR ',f ,r P r ` "' "'°` " DATES"
ij `•{ I�ITT. 1293 / LOCATION �i 1\ 9 1 2 9 3
ii S.R. NO.
SUBDIVISION NAME f'76IJ LOT N0. SECTION OR BLOCK N0.
ii
HOUSE1 MOBILE HOME 0 BUSINESS ❑
House Trailer 800 Gal. 400 Sq. Ft.
N0. BEDROOMS i N0. BATHROOMS Two Bedroom House BLD.Xa,1 600 Sq. Ft.
GARBAGE DISPOSAL UNIT "-YES ❑ NO 0 '. Three Bedroom House , 7 900 Sq. Ft.
AUTO. DISHWASHER YES Q� .,NO
❑ Four Bedroom-Hous 1000 Gal.. 1200 Sq. Ft.
AUTO. WASH. MACHINE I YES NO ❑p , F "' f.;
SITE SUITABLE YES Of NO ❑
SIZE OF TANK �° gal.'
NITRIFICATION FIELD it'% sq. ft..i + r .j �
DEPTH OF STONE.IN LINES: h
WATER SUPPLY: Indiv;idual_.,Q�w Public
t. a y
TMPR(1VFMF.NTS PF.RMTT IRY _�4 f��^' TUCTAT T Fil AVi �%.
I CSD xlrcp"s '-bn w1\1 '/
DAME COUNTY ENVIRONMENTAL HEALTH SERVICE REQUE T
' APPLICATION IP/ATC OSWW REPAIR
Name f � k4wo Telephone Number -2Z&, qd g' d5%('
Address J Jam® &
Mailing Address (if different from above)
Email Address: T�
Subdivision Name Lot
Directions 6, /, � P i;�C C e r r _
-o 3 D d
Date System Installed Name System Installed Under
Type Facility 6 u S e Number Bedrooms_ Number People Served
T Water Supply 0(t A) Q/ Specific Problem Occurring /11�
e �
Uk)(216AM
Date Requested 57/ S� / 3 Info Taken By
THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY
KNOWLEDGE, AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED
FROM THIS APPLICATION.
Signature of owner or Authorized Agent
Initial Fee Date REHS
Revisit Charge Date Reason
Revised 2-2011