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217 Westridge Road Lot 21DAVIE COUNTY HEALTH DEPARTMENT n Environmental Health Section `4- P. O. Boz 848/210 Hospital Street 7 Mocksville, NC 27028 (336)751-8760 Account #: 989900573 Tax PIN/EH #: 5881-03-4934.21 GJ Billed To: Glenn Johnson Builders Subdivision Info: Westridge 2 Lot # 21 Reference Name: Location/Address: Westridge Rd-27006 Proposed Facility Residence Property Size: 110 x 199.92 ATC Number: 4128 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FI/VE YEARS. Environmental Health Specialist's Signature: Date:(4-71 `� s CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit 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. �q JA-- Septic System Inst; Environmental Health Specialist's Sil DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street a: % % - s S Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 989900573 Billed To: Glenn Johnson Builders Reference Name: Proposed Facility Residence Tax PIN/EH M 5881-03-4934.21 GJ Subdivision Info: Westridge 2 Lot # 21 Location/Address: Westridge Rd -27006 Property Size: 110 x 199.92 ATC Number: 4128 **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 A/ #People f #Bedrooms c --r #Baths I Dishwasher/ Garbage Disposal Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type /J #People #People/Shift #Seats Industrial Waste: 13Lot Size Type Water Supply C 0 Design Wastewater Flow (GPD)_ 6 Site: New Repair ❑ System Specifications: Tank Size GAL. Pump Tank GAL. Trench Widtlr�'Rock Depth /.)- Linear FkTo�6 Other: AIn tOS aya s Required Site Modifications/Conditions: ncepted Sysmmo be use 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.m. on the day of installation. Telephone # is (336)751-8760.**** !y/L - P l'jq pA 4° Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMI Davie County Health Department U tS EnvironmentaiHealth Section P.O. Box 848/210 Hospital Street JUN 2 8 2005 Mocksville, NC 27028 (336) 751-8760 ENVIRON,�1 n Al E111TAL HFA I T1 I ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for //��instru`/ cttions. 1. Namo Lo be Billed-i1-IeA'' JDUI�l�O�i Contact Person (�7I 7��,nSO,t Mailing Address 1 &-S+Ouk Home Phone 33C�'9�t0-SFj City/State/ZIP dy4✓lee J�Z' Business Phone 336-9�D-S6s7 2. Names on Permit/ATC if Different than Above A/ /J Mailing Address �_�Yt,/Us/JC4%�,� lelCity/State/Zip ; T41a4ce 3. Application For: ❑ Site Evaluation L3Improvement Permit/ATC ❑ Both 4. System to service: E H use ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. Type system requested: fa -Conventional ❑ conventional modified ❑ innovative pace^epted 6. If Residence: # People � # Bedrooms # Bathrooms o� BDishwashar aage a ki rbDisposal QNng Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: i#Seats '� Estimated Water Usage (gallons per day) 8. Type of water supply: 2—County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes, what type? ***1.A1P0RT4NT*** CLIENTS MUST COMPLETE, TRIC REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: if a �4 Z g t? (7 Z G Tax office PIN: 0 676m � / —y 3— V ` 3 y Property Address: Road Name ��✓�'' City/Zip °/4 WRITE DIRECTIONS (from Mocicsvillc) to PROPERTY:` 1Z-eIF, ��ofs -J--Q CI-) s1 If in a Subdivision provide information, as follows: Name: Section: Block: Lot: 2` Date home corners flagged: tO 2�`-> } 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 nun responsible for all charges incurred from 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 ,g / to conduct all test'ng procedures as necessary to determine the site suitability. I DATE O SIGNATURE. THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Sign givcn_&f Revised DCHD (05103 Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. C' i �S7i Invoice No. Y0 05/1 3/;295-1226 LX FAXA 336 747 8979 5/11 122"AJ3tl (tlo (rl ri Zti PRUDENTIAL CAROLINAS 0002 16001/001 APPIJC47ION FOR SITE EVAi,UATI0N/IAjrn0MIENT PERMIT & ATC Davie County Health Department b7V1.-0,7n7CmtfffKe3/t0:iecd0nr �A D.C_ Box 646/210 Uosp1tal Street A?' 3 �a� Mockcvl.j.].e, NC 27020 U (336)751-8760 n„ •.eZMPOFiTA2VT*"r 7`82S ADpI;SCAS2O.W CANNOT DOW PAO=2SED LDT,T.ES8 ALL THE zNYOR*ra�^'oN T9 A2zovxpY.n. xeEmrr t:o tue xmzoRbtxwxON IsvJLLET= for 1-st.xvc �Tco A. frame to bo sizlca 50SetN K. Trerp% 4 Contact Deraon - Z StWIF r aaixin3 Addra..a 1A3_46 WO¢rpwf� Ctss i711� Homo PLoaa 3y310�I�� CL12r/Hae�ZZP YIUVNQ(.ru ��.• -Tontun _ Ds."... Phone 316-14-1' 1617-1 1. Nage On re—lt/AXC it DLZZUo cnt-than AbvVs /tai1ing At]nr�rra GiCy/9CSta/Sly � 7. appil.catioa Per: ilrSitC F.Vall &"r -LC x CJ Imp-avomont S•artait:/JLTC Q IIot t 4. xyebac/ to Serv:Cc: obw1suve 0 wablia 110=0 D Sun:L-vean D zaauatry 0 Other r. Trwa OyatAm raqueatnd, y,rcoaragtioAal Q con,rootson;l modified ❑ ianovativa s . I:E A641danca: ,.✓ It 8eop10 g Dedroobus I <hWanhar Warbago asnyosai W"'aAhiag 110 ft .oe 07Dancmaat/Ho Plumbing 7. ZZ n4e1a4*z/SnduObsY /otthars V -11y tyyC M YaogZO tt sinka 0 COMIOaeY a ZAoNar. Y r7r1na_xa u Nataor Coaxer. IF FOOD.SMUVTCZs ff sooaato Entisaa.tea Wal:or aaago (Vallons Der day) E. 3Ysae or; xatar supply: aveouaty/City O Ne11 ❑ Cou=unitiy !. Do you ant1e18aee &44&Uano ez expansions ottlle taeility Wis systuai is intended to servo? ❑ i'cs µrl�p Irycs, what typo? A"J-- CLIMTS AIUST COAfPLGTGTHE RI:gUrttPD I -ROPE• RTY INVORMAT10:4 aQUxsTr,.v II8[_AIV, $ttlfera PLAT.rS1TL PLAN AfUSTDz-:SUBAII77VD by tic cliair with TI -115 APPLICATION. Property Dirnexulo": AM X 1"M17— IVRITE DIRECTIONS (rrani Mucluvilla) to PROPERTY: Tax orate I'I11. u' s 86103tAl9,3_ q 1QS,,$ Etat A.-), 1 S Zsb , t;� J Property Address: Nam .c Nae WtS � t#\� CN� ` �O V &3 aawN o `�•� CiwrzIp biv w w Z'10o4 uwwpaas '?-6 Ao %A1 L'teST ZRi irin a Subdivisi 'on provide information, as follows: m`W rV��a.��s�M 'O �� �`si tt;�06►F �Ll Na e: kc LOT OAS 7r ' Seelloa: Block: Lot: _�_ Data home corners flagged: . •(b•��. LcF�• (,arwn�- w�11 b�..,.�otsr� fr-tj 5 MEb 'rids is to certify that the inforn-11on provided is correct to the best or maiy knowledge- I underslathat any rmit(s) issued horcaCter arc subject to suspension or revocation, if the site plana or jutendcd use change, or if Use Infar7hation ttubauttcJ in this application Is falsiticd or clinaged. I, also, r4rportilb1rjor fill drarars WcurrctUroin -Itis applttatiatt`S, tterclsJ,give conscnt.to eiaoAu[peri¢eclltepresetttativo-ottdicDavie Couj:tYFlcnithDej artnu/lt' to enter upon ahave describeU property located in Davjc County and owned Ly �e lay/ S tWArl► twS eft - to Conduct :Ill tcprocedures ax ncccssury to deternine the site at - bil ,i DATE CMOs. Os. SIGNATrjI2E r l► " �r TMS A.12£A MAX DZ /]SLD TOR DRAWING YOUR SITE PLAN (InC11a all of the foliowingt Existing and proposed properly limes anil dimensions, structures, setbacks, and septic locations Site Revisit Charge Datc(s): Client Not;lienuoa Date: r.—USt Sign j:ivoo Account No. %�- 11cvisedDtUD(tISMJ YnvotccNo. L 05/13/2005 12:27 FAX 336 747 8973 CALIBRE AN 10003 Davie) County, North Carolina Spatial Data Explorer Page 1 of 2 dp Click on the•Mep to:: Map.Li r c'' Parcels — Zoomin ZoomOut Recenter•Map. 'Identify;, ;ibkSVlril j ZX (` A j �rawserect Radius $aa' (test Zoom Factori 0 Boundary N''x/V'.`' SNE , r CensusTra 1 0443 i + 'f' M?� �F. Ctty, Bound J. �I 4 3482 ��"� 4.+� ti -, r CountyZor g ;A. �W Sw,1 Find Adjoining Parcels e, County /0: Eel 1000010 e, Account Numbera2521065 w PIN:5881034934 el Legal 1:LOT5 21-22 WESTRIDGE e Owner Name: WININGER JOHN DAVID •I Owner/Address 1: WININGER JOHN DAVID 40 Ownor/Address 2: WININGER SANDRA S • Owner/Address 3:209 WFSTRIDGF ROAD City State Zip: ADVANCE .NC 27006 - 7298 •i Land Value: $56,000.00 e; Building Valu9: $92,000.00 M 1 r "'• SC • Land Unit /Type: E611000010 J LT • Deed Sook/Page: 0050 10617 • Deed Date: 2004112/30 • Sales Price: $159,000.00 • Property Address: 000209 000209 RD • County Zoning: R-20 • Census Code: • City Coder • Fire District. ADVANCE • Flood Zone: ZONE X • Flood Community: 37030a • Flood Panel., 0045 C • Flood Map Date: 12-t7-1993 (—' Drlveways r Rail Lines j— streeteent F. US1NC HIM Multi Syi U :N .r, Aetlpil Phot Physical • ' Creeks aqd r_ F-914 Add. ( ; Fire'D' A j- Schools Y; �Dl%a;�iiti;L MAP Cl This map As preps Inventory of teal l within -this jutisdc compiled'from re, plats, and other F and data. Users c hereby notified th http:ilsdx.roktech.net/servlet/com.esri.esrimap.Esrimap?Name=Davie&Cmd=C Ik&Left=1... 5/13/2005 Multi Syl E911 Fire D 0 09 Flood Pane r Flood Zone �; Parcels School Dist D6 Multi Syl r Solis • r,: Town Zonio ' (—'Townships Multi Sy1 (-.Voting Prec M 1 r "'• SC • Land Unit /Type: E611000010 J LT • Deed Sook/Page: 0050 10617 • Deed Date: 2004112/30 • Sales Price: $159,000.00 • Property Address: 000209 000209 RD • County Zoning: R-20 • Census Code: • City Coder • Fire District. ADVANCE • Flood Zone: ZONE X • Flood Community: 37030a • Flood Panel., 0045 C • Flood Map Date: 12-t7-1993 (—' Drlveways r Rail Lines j— streeteent F. US1NC HIM Multi Syi U :N .r, Aetlpil Phot Physical • ' Creeks aqd r_ F-914 Add. ( ; Fire'D' A j- Schools Y; �Dl%a;�iiti;L MAP Cl This map As preps Inventory of teal l within -this jutisdc compiled'from re, plats, and other F and data. Users c hereby notified th http:ilsdx.roktech.net/servlet/com.esri.esrimap.Esrimap?Name=Davie&Cmd=C Ik&Left=1... 5/13/2005 DAVIE COUNTY I-IEALTII DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INrORMATION Account #: 990003622 Billed To: ' Josepeh Freeman Reference Name: Proposed Facility, Residence Water Supply: On -Site Well PROPERTY INFORMATION 'Tax PIN/EH #: 5881-03-4934 Subdivision Info: Westridge 2 Lot # 21 Location/Address: Westridge Rd -27006 Property Size: 11 Ox 199.92 Date Evaluated: �:S Community_ Evaluation, By: Auger Boring_ ✓ Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position -,L.- L Slope % HORIZON l DEPTH 6�i Texture group Consistence i Structure Mineralogy HORIZON 11 DEPTH i- G Texture group Consistence Stricture Mineralogy HORIZON 111 DEPTH � Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITL' Ar I CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: OTHER(S) PRESENT: LEGEND ' Landscape Position It - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nosc 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 Ioist 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 VI' - 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 rill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitablc), U(unsuitablc) Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification - S(suitablc), PS (provisionally suitable), U(unsuitablc) LTAR - Long-term acceptance rate - gal/day/ft2 T'Nr`11(l nC 100 (T?, 4- 1) AUTHORI *ATIOM,NO: 0502 DAVIE COUNTY HEALTH DEPARTMENT t ,f' Environmental Health Section PROPERTY INFORMATION . Permitt -e's * . Mocksville, NC 27028 Subdivision Na 7 P.O. Box 48 Naine•� _Tai_. ar..-tom* me Phone #: 704-634-8760 Directions to property: 11 - T o t -� Section: Lot: ~ AUTHORIZATION FOR WASTEWATER { Tax Office PIN:# SYSTEM CONSTRUCTION[ Road Name: Zip ? b **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article 11 of G.S. Chapter 130A; Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) (�� ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED DAVIE COUNTY HEALTH DEPARTMENT i IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION �Perrmttep" s .. file':'= ""��+ � �� �'� < -:� � Subdivision Name. Directions to property; r IMPROVEMENT PERMIT Section: Lot: ' Tax Office PIN:# - - Y"1 g.'F ��- �•:'. ti.�r.te y. „�°� '" 4, e) �,i�'_ , j t _!� e. Road Name.. ! zips **NOTE** This Improvement Permit DOES NOT authorize the constriction 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) G***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. tI RESIDENTIAL SPECIFICATION: BUILDING TYPE push # BEDROOMS , # BATHS "t # OCCUPANTS GARBAGE DISPOSAL or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE �V TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) 6� NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE /O D O GAL. PUMP TANK GAL. TRENCH WIDTH 3 ROCK DEPTH LINEAR FT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: OPERATION PERMIT SYSTEM INSTALLED BY: AUTHORIZATION NO. OPERATION PERMIT BY: DATE: "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 IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 05/96 (Revised) ra. DAVIE COUNTY HEALTH DEPARTMENT * a IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Name: Directions to property: I r Subdivision Name. Section: Lot: t IMPROVEMENT PERMIT Tax Office PIN:# Road Name: Zip: E **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) t� ***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; L :. # BATHS # OCCUPANTS ` GARBAGE DISPOSA�� or No i r COMMERCIAL SPECIFICATION: FACILITY TYPE "�L _ # PI iOPLE ' # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) 4—NEWSITE REPAIR SITE `PUMP SYSTEM SPECIFICATIONS: TANK SIZE /0 U' -GAL' TANK GAL. TRENCH WIDTH 3 ' ROCK DEPTH LINEAR FT. D I OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: w/ OPERATION PERMIT SYSTEM INSTALLED BY: 4 AUTHORIZATION NO. OPERATION PERMIT BY: DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 1 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 05/96 (Revised) U,\ - j l :a0 DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION \N Kk\N tPPLICATION FOR IMPROVEMENT PERMIT (REPAIR) c (� NAME �-. e 5 e PHONE NUMBER ADDRESS 1 D W Q's SUBDIVISION NAME �1." DIRECTIONS TO -SATE 1A �� P Q-4�_P„ \\�L !!, Q ,�_. a'�0()e , wk -- l \ tU - ."dvs LOT # d. 1 DATE SYSTEM INSTALLED 5 4 NAME SYSTEM INSTALLED UNDER TYPE FACILITY 1'�y �Q NUMBER BEDROOMS 3 NUMBER PEOPLE SERVED TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING �gNx- o.� DATE REQUESTED -V� �� `"� INFORMATION TAKEN BY A This is to certify that the information provided is correct to the best of my knowled e, and that I under am sponsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT`�` ��/� •� Rev. 1/93 1?�\ -s �` ��.,. Environmental Health Section P. 0. Box 848/210 Hospital Street Courier 09-40-06 May 19, 2005 Joseph A. Freeman 1346 Underpass Road Advance, NC 27006 Re: Site Evaluation/ Westridge —Lot 21 Tax Office PIN: #5881-03-4934 Dear Client(s): As requested, a representative from this office visited the aforementioned site on, May 18, 2005. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site, the site was found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions, please feel free to contact this office. Sincerely, kec'tox -S C;21azzA. Robert B. Hall, Jr., R.S. Environmental Health Specialist RBH/dlf Enclosure(s)