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132 Chandler Drive Lot 5DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001248 Tax PIN/EH #: 5749-63-6844.05 Billed To: Mike Hester Building Co. Subdivision Info: McAllister Park Lot # 05 Reference Name: Mike Hester Location/Address: Chandler Way -27028 ProDosed Facilitv: Residence ATC Number: 4300 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 T eatment and Disposal Systems). THIS AUTHORIZATION FOR WASTE W N I VALID 7R A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: I Date: Ww,, CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completio shallcate the system described on Improvement/Operation Permit has been installed in compliance with i ellofl C er 1 ,Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO W be takM t at the system will function satisfactorily for any given period of time. �0 � z STt Septic System InstalleBy: F1M^ ^S ►� Environmental Health Specialist's Signature: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Q 0(0 Mocksville, NC 27028 (336)751-8760 0� IMPROVEMENT/OPERATION PERMIT Account #: 990001248 Tax PIN/EH #: 5749-63-6844.05 Billed To: Mike Hester Building Co. Subdivision Info: McAllister Park Lot # 05 Reference Name: Mike Hester Location/Address: Chandler Way -27028 Proposed Facility: Residence Property Size: 130x238 **NOTE* ThIs�mpro4ement/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 1100SN2-- #People #Bedrooms 3 #Baths 2 - Dishwasher: Dishwasher: e Garbage Disposal: Mr Washing Machine: 0"" Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ rV Desi Wastewater Flow GPD �7 Site: New�Re air ❑ Lot Size Type Water Supply Design (GPD), p System Specifications: Tank Size II I� � GAL. Pump Tank (COO GAL. Trench Width� Rock Depth tJ s Linear Ft._Z� Other: `i 'DISTi�1�1rt0�9 �07l � QeC*'�'n� to i 'yb0 aar.) �C"i-�cntii Required Site Modifications/Conditions: �Ogj-At-t- 0-3 "Jtuo2 IX to or -P (h.P. �•.�sS L j 1'1 IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p. .,p,,the day of installation. Telephone # is (336)751-8760. yo **** Alex. 1Co' IC�BoacH -rap J PM 37" nava t�Z \ 7 c -o 40 F c� I 37' -7o' w nvironmental Health pecialist's Signature: e: DCHD 05/99 (Revised) JAN 1 9 2006 ......mnnIMFI1IAF HFJU.m PLICATION FOR SITE EVALUATION/IMPROVEh1ENT PERMIT & ATC Davie County Health Department Environmental Healt/y Section P.O. Box 848/210 Hospital Street I Mocksville, NC 27028 (336) 751-8760 *** i2YAZGZ'*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORI-IATION IS PROVIfDED. Refers to the INFORMATION BULLETIN for instructions. 1. Name to be Billed M 1 /L , G %�f /�� I, ��'. Contact Person i4l /r//r Mailing Address 1 a G 0441 home Phone City/State/ZIP a '"✓Ly i l! ��C . sY/ Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip � div •. � � � - L' �"� 3. Application For: ,,.❑, /Site Evaluation ®improvement Permit/ATC ❑ Both 4. System to Service: lyHouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other _ 5. Type system requested: Lid' Conventional ❑ conventional modified ❑ innovative pacCepted 6. If Residence: # People # Bedrooms S # Bathrooms (�isliwasher CRGarbage Disposal Washing machine 7. If Business/Industry /other: verify typ # Commodes # Showers ❑Basement/Plumbing ❑Basement/No Plumbing # Urinals # People # Sinks It Water Coolers IF FOODSERVICE: # Seats IEstimated Water Usage (gallons per day) S. Type of water supply: L7 County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 1310 If yes, what type? ***1A1J'0Rt4N2-** CLIENTS AIUST COIfPLETL• THE REQUIRED PROPERTY INFORMATION REQUESTED BEL.OIV. Either a PLAT or SITE PLAN AfUST BE SUBAfITTED by the client with TRIS APPLICATION. Property Dimensions: i t/104 ? r- %L a ��,,{{33 Tax Office I'IN: # (57 t/1043- ANI -6 Property Address: Road Name+ "i s %� rye' City/Zip If in a Subdivision provide information, as follows: WRITE DIRECTIONS (from Mocksville) to PROPERTY:' C/.. fit �.7/ C1 r i ✓, j V Name: Section: Block:- Lot: S Date home corners Ragged: /--/5-c(. This is to certify that the information provided is correct to the best of Lny knowledge. I understand that any permits) 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 Iain respousihIe for all charges incurred frons this application. I, hereby, give consent to the Authorized Representative of the Davie County IIealth Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. c DATE �" � �7 � L-'' �' SIGNATURE 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). Sign given Revised DCIID (05/03 Site Revisit Charge Datc(s): Client Notification Date: EIIS: Account No. Invoice No. --FOR LOT 34 7r�-_ 1823.04' S _'39' 45 W DB 86 PG 427 ' r - 5 88.00' 74.00' 65.00' 114.E1'104.00' TOTAL 104.00' �� CD MOM A £A • / 32261' S 2' 39' 45' W 10a 216 j r I I 1 To rA� 8 92 ()o. NAA �v / j I 43Z00 10800. 7s• 00 d i -coo , 3 ! i ! t 79 • j 10.R.0p 48.00 cn V n� V � 13 I 1 II j� L'13-� ! �gr916z� 0' RD. R/�',ygc_115- • W 'Y , I I �-_L. 12 AfD,�'R�4 525�00� i, 4 ~� 9 �e 01 O�} / �- •/ *; 1% Z, . S 12-41-4- 2.4 • -- - _j to I _ �� 4- - L Iy S 2 w - ,;, m �' 1 . C 4� Sp R R�475 �. 220.78_` �' o� 1 ip \� L_ 22 50 o �f 20' " m� l X715' Pq PUBLIC RD M o�o11N �� QIr I 1 N 1j's0 S1• L41 �. I _0 107 co IL6 I S 2'w �� IrN N 4'E 210.19' 168.00' j oI I l S6 w OJ 1 i h N O OLi Y q �1 q 04 i s0. -W I 1'O 0;. 210.14' -I>-Do 168.00 '• Iw� r - - -- O! XN 102-00 102.00' 1 S 2' W I V `. ! O TOTAL 1009.79' N 0.39' 32' E. 21 D.09 t:--c)'t - I I ----- - JI It o I OI ^1 i 1 I i m 0 1 ZLo cc r' o -_ a �' N !IN PLAT KEYNOTES: S 2 w I �i `0 ! 210.02' i>I �i 10'x 70' SIGHT TRIANGLE . 4 �' 1 I m b o a 1co Cc Z O TYP. 5'W U Tl U TY k DRAT Icy N _ ON LOT SIDE OF ROAD R O 1 213.94' -c• L O 8'W SIDEWALK EASEMENT ole 1. _ ON SIDEWALK I ----_---_'� __� o�i 2 I o O20'W DRAINAGE EASEMEN 1,17' S 2' w 1 i 6 1 o a ON CULVERTS AND DIT 11 3 O O 9.17 S 2' W 20'W SEWER EASEMENT -- I ' - N 2' _ E 213.98' T U6 TYP. BUILDING SETBACK 70.78' 103.60' I - - - - - - -- - - f•Q 1!^ ! b O 20'W UTIUTY EASEMENT OI I o OFFSET 5' FROM PROPER ! p� I- o w 'n cr II-- c� L7 70.00' 62.00' I 50.01' � I - 214.06' 23 E J a U .FOR SOT 3' � H5 LOT 59 AN 2 4 2006 SARA HOLLAND WLL 8K 4 PG 48 E1w'RONMFN>`AC y ! r. •�HE4LN DEVELOPER R.C. SHORT AND ASSOCIATES, L.L.C. NOTE: (336)407-6424 ��. 6/405 APPLICATION FOR SITE EVALUATION/IAIPROVEAIENT PERMIT Davie County Health Department O EnvironmentaiHealth Section P.O. Box 848/210 Hospital Street APR 73 Mocksville, NC 27028 2005 (336) 751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THEME=gyp INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed ,�'-I�c.: zC )�1 1 r� Contact Person "31-7 :� Mailing Address — �i1 t�E"� Y' �S "i'' Home Phone '//— City/State/ZIP L:J�s h'r� y ��=�`� 7/6 } Business Phone -:16 7 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: �13 Site Evaluation ❑ Improvement Permit/ATC ❑ Both 9. system to Service: 111 -House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: 0 Conventional ❑I conventional modified ❑ innovative 6. If Residence: # People ? # Bedrooms/ ,�� ' , � - ITt #Bathrooms �� L�DisYiwaaher ❑Oarbago Disposal IBWa�shing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: It Seats Estimated Water Usage (gallons per day) 8. Typo of water supply: IN' Ceounty/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 13-1` If ycs, what type? ***DIfPORTANT*** CLIENTS A1UST COAIPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SI/BAI177'ED by the client ivitl: THIS APPLICATION. Property Dimensions: n 1e •f -f P,1 WRITE DIRECTIONS (fron Mocksville) to PROPERTY: Tax Office PIN: i/ Property Address: Road Name (5/A n 11211 City/Zip If in a Subdivision provide information, as follows: Name: 68 I S -kf f' k Section: Block: Lot: 51 i Date home corners flagged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any pernlil(s) issued hereafter arc 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 ani responsible for all charges iacnnrrcil from this application. I, hereby, give consent to the Authorized Representative of the Davie County IIcallh Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. �� SS' , - DATE �.3 D SIGNATURE—� TIlls AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of (lie following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Sign given Revised DCIID (05/03 Site Revisit Charge Datc(s): Client Notification Date: EIIS: Account No. Invoice No. T y APPLICANT INFORMATION Account#: 989900035. Billed To:' Richard Short Reference Name:. Proposed Facility.: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5749-63-6844..05 Subdivision Info: McAllister Park Lot # 05 Location/Address: Sain Road -27028 Property Size: as platted Date Evaluated: q 4 ®J Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut SITE CLASSIFICATION: '� —' EVALUATION BY: v LA_F_ LONG-TERM ACCEPTANCE RATE: ' �' OTHER(S) PRESENT: REMARKS:�l-I G h..�-tTt--1 a 6 sc- poyvp 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 ois 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 611- 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 DCI ID 05/99 (Revised) Landscape position Texture group ���---® Consistence MR ����1:����a�� Mineralogy WRICA Texture group Consistence �� r� rz�� ��� s �■■� �� Mineralogy HORIZON III DEPTH Consistence HORIZON IV DEPTH Texture �■�s��s����� Consistence���■��������e�� RUM SOIL WETNESSSAPROLITE CLASSIFICATION �c-�tc�■����-���� SITE CLASSIFICATION: '� —' EVALUATION BY: v LA_F_ LONG-TERM ACCEPTANCE RATE: ' �' OTHER(S) PRESENT: REMARKS:�l-I G h..�-tTt--1 a 6 sc- poyvp 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 ois 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 611- 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 DCI ID 05/99 (Revised) er APPLICATION FOR SITE EVALUATION/IAIPROVEAiENT PERK TC Davie County Health Department DEC Environmental Health Section 1 6 2004 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 ENVlRO NMENTAL Hfq(TH ..(336)751-8760 DAV(ECOUW ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed 'lzlaA,c 1 x,. c Contact Person / L ��•��c� Mailing Address 616> ILI-Iler Home Phone -77-cl" City/State/ZIP Ly/ n/,$,�� /r.-,.+ /�%/ L j Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to service: 13-1,011se ❑ Mobile Homo ❑ Business ❑ Industry ❑ Other 5. Type system requested: 13-5onventional []'conventional modified ❑ innovative 6. �lf/Residence: # People # Bedrooms 3 '�� # Bathrooms ! eDishwasher ❑Garbage Disposal ' Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks # Commodes # Showers # Urinals It Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) S. Typo of water supply: 12- County/City ❑ Well ❑ Community 9. Do you anticipate additions or expaIlsions of the facility this system is intended to Serve? ❑ Yes ❑-N'o-- If ycs, what type? ***Il11P0RT11NT*** CLIEN'T'S J1IUST COAlPLETETIIE REQUIRED PROP)RTY INFORMATION REQUESTED BELO\V. Either PLAT or SITE PLAN :IUSTBESUB.MITTED by the client with THIS APPLICATION. Property Dimensions: 1 %) - trl, ej- IVRITE DIRECTIONS (from Mocksvillc) to PROPERTY: Tax Office PIN: iE 7�i- 4.3 �;?q J �, ' -�L �S,- ; 4Property Address: Road Namc 3 -2b City/Zip %�y�i_5y1 �;- _ l-� 7G� X J�L'ti •• t.�_s �etc,� If in a Subdivision provide information, as follows: Name: V-A "aD Section: Block: Lot: Date home corners flagged: W' Ll- This l- This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter arc 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 l an: responsible for all charges iucuured frons this application. I, hereby, give consent to the Authorized Representative of the Davie County Ilcalth Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the sites .h DATE /S SIGNATURE % 71'� TIIIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of t11e folIolving: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Sign given Revised DCIID (05/03 Site Revisit Charge Datc(s): Client Notification Date: ' EIIS• Account No. Invoice No. B I FACTORSao©ate®��a ' DAVIE COUNTY HEALTH DEPARTMENT HORIZON I DEPTH Environmental Health Section Consistence Lon Soil/Site Evaluation APPLICANT INFORMATION HORIZON 11 DEPTH PROPERTY INFORMATION Account #: 989900035 Tax PIN/EH #: 5749-63-6844.05 Billed To: Richard Short Subdivision Info: Richard Short Lot # 05 Reference Name: Location/Address: Sain Road -27028 _ Proposed Facility: Residence Property Size: 5 acres Date Evaluated: Water Supply: On -Site Well Community Public / Consistence Evaluation By: Auger Boring Pit Cut FACTORSao©ate®��a HORIZON I DEPTH Consistence Lon HORIZON 11 DEPTH Consistence Mineralogy— HORIZON III DEPTH Consistence HORIZON IV DEPTH Consistence Mineralogy SOIL WETNESS MIN V • • M 9 1 CLASSIFICATION SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE. �' 3 –�•3S REMARKS: O C.) LEGEND r � EVALUATIONt��a ��► �a� OTHER(S) PRESENT: -Z @ gj ac s- 0? S, cg— 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) M LVED Davie County Health Departm nt Environmental Health SectioyA'y 21 Pnp ' P.O. Box 848 ,DC HEALTH • 210 Hospital Street 1 Courier # : 09-40-06 Mocksville, NC 27028 Phone: (3361- 753 - 6780 Far.: (336) - 751- 8786 ON-SITE WASTEWATER CER N FOR DWELLING (Check One) Replacement Remodelin Reconnection Name: MOA - Je_� e r A Phone Number. D 4- to 5 9~ 1 1 9 (Home) Mailing Address: Iia Cid--A � `e- .Dr (Work) M OC.KS V 1 I l e. a70,Z-bU Email M be Y'A S u I cG • co rn Detailed Directions To Site: R W u 1 t X 1-D 1.l) GLA'' d YY l D LKSV I I 1 e-. - L -e -t tt- �7)rC' 1.1 11 o i �"�' G e - r rclr ,� �{�•�-Ila Property Address: �[ Please Fill In The Following Information About The EXISTING Facility: / Name System Installed Under: Ake k&L-q- Type Of Facility: AUS6-2 Date System Installed (Month/Date/Year):� Number Of Bedrooms: 11� Number Of People: Is The Facility Currently Vacant? Yes If Yes, For How Long? Any Known Problems? Yes l� If Yes, Explain: Pa Iter D('. Please Fill In The Following Information About The NEW Facility: $' & " Y(3 (Q' b " G-ree I o -n Type Of Facility: P CO T1s Ll n n Number Of Bedrooms: Number of People Requested By: La Date Requested: 15 - 19 - I C��- (Signature) X - (Signature) Qt -+P- t^ I) O 1 Co • 331, - 7t, 4 - 4 For Environmental Health Office Use Only pproved Disapproved �.- .:1..1 n �enn:.n �L„n,. 1L l.� Dd�2l7C' _��% �2s./11/7Z;" Li Environmental Health Specialist Date: 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: Paid By: Money Order #. 0 / By: Account #: ?5 a Invoice #: hn a. (I rk C,�1ecf< U