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175 Cedar Ridge Road Lot 1 Box PropertyHEALTH DEPARTMENT RELEASE Davie County Health Department „ 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: David E.Lee Address: 175 Cedar Ridge Rd City: Mocksville State2ip: NC 27028 Phone #: (336) 940-2505 For Office Use Onhr *CDP File Number 121089 -1 J6 -060 -AO -009-01 County ID Number: Evaluated For: HDR/WWC PERMIT VALID 4/ 1 5/ a 0 1 8 UNTIL: Property Owner: David E.Lee Address: 175 Cedar Ridge Rd City: Mocksville State2ip: NC 27028 Phone #: (336) 940-2505 Property Location & Site Information R Rid 175 Cedar Ridge Road Address Subdivision: Hickory Hill !Janice Moore Phase: i Lot 1. Road # Mocksville NC 27028 SINGLE FAMILY Township: *Structure: Directions # of Bedrooms: 3 # of People: Hwy 64 E Lefto at Hickory Hill, Hawthrone Rd. Left on Cedar Ridge House with white fence. First on Left *Water Supply: NIA Basement: R YeS ❑ No 'Proposed Improvement: Out Building 802 Type of Business: Total sq. Footage: No. Of Employees: It is the responsibility of the owner to maintain a 5' minimum setback between the wastewater system and any part of the structure foundation, including porches, decks, and any other appurtenances. If you are unsure as to the exact location of the septic system, please have a licensed installer or inspector locate the septic system for you. The local county health department in no way implies that the proposed construction meets the required setbacks from the septic system unless otherwise noted. This release only shows that this property has an approved wastewater system that appears to have met the permitting requirements at the time it was installed. ._.�v�ylDci�eQ� �{-Zvl3 This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps. Signature Required? QYes ONO Applicant/Legal Reps. Signature: *Issued By: 2244 - Daywalt, Andrew Authorized State Agent: *Date: A *Date of Issue:. 0 4/ 1 5/ 2 0 1 3 **Site Plan/ yawing attached.** O Hand Drawing OImportDrawing Total Time:(HH:MM_).._, 1 Ho�O�MiDnute Davie County Health Department 4;) P 6.' Environmental Health Section P.O. Box 848 O ,�, 210 Hospital Street O U ..: ' y Courier # : 09-40-06 1911 I� Mocksville, NC 27028 Phone: (336) - 753 - ON-SITE WASTEWATER CERTIFICATION Fax: (336) - 753-1680 (Check One) Replacement Remodeling Reconnection Name: � ] L 49 Q Phone Number 3 36 � � �a � d��©S (Home) Mailing Address: ff S C edu �A(Work) Yt_ 0� eks: �(o �% C % U o�p Email Address• X ,. / [ ( ® L1g 4y oa, ec wk Detailed Directions To Site: i0 * r6� fcyJ '► fk ar j-, s,,4& 4-tff " /7t e kw5, L`f dll` C2d-o.. k �_ C — hL-Lt r e uVlA t Oji -P &.Vtt , -J; Ysl ol -' L -P w� t� LOl Nice Moat ro ,,.d �cL-oal i�� Property Address: Id e_ �cC O e d 9 .41 Please Fill In The Following Information About The EXI/STING Facility: Name System Installed Under: � ( c K«-r�Y (T�-vt y*t' 5 Type Of Facility: Date System Installed (Month/Date/Year): 10—,1003 Number Of Bedrooms:_Number Of People: Is The Facility Currently Vacant? Yes No If Yes, For How Long? Any Known Problems? Yes No If Yes, Explain: .r»„r ��-ra-rrr► Please Fill In The Following Infor ation About The NEW Facility: Type Of Facility: d 8 Number Of Bedrooms:Number of People Pool Size: Garage Size:' Other: Requested By: CLAA L2.1e A Date Requested: —�n % 3 For Environmental Health Office Use Only Approved Disapproved Environmental Health Specialist. Date: *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 (ChecV Money Order # Amount:$ Paid By: L P— ry Received By:L/= J)(/Vf/Glc tt Account #: Invoice #:1 ft? '�- I V00 1/2" EiR Fnd J Ln Tax Lot 54.11 0 Tax Map J-6 6 n/f William A. Burnette .A DB 203 0 PC 391 T—Sor w/cap Fnd LEGEND R; N Right -of -Way E1P - Existing iron Pipe EiR - Existing iron Rebar P -Point i,M - Concrete Monument ]RS - iron Rebor Set 1/2" PA - Property Line C A - Controlled Access RCP - Reinforced Concrete Pipe CMP - Corrugated Metol Pipe CPP.- Corrugated Plastic Pepe -£- 100 year flood Boundary -0- Overhead Utilities -X- Fence Lot 2 o "Division of the Janice Moore Box Proppity PB80PC3 N 10035'56"W 363.90' total Lot j , (PB 8 0 PC 3 1.010 Acres +/ Center Line s - Center Line EP -Edge of Pavement FC - Face of Curb PP - Power Pole - Radius CH - Chord Distance P(0 - Part of S - Sight Easement D@ - Peed Book P let B. CB - Catch Basin FP 1'eevneeL Post EioC - Hack o curb J 40 0 40 80 12 o 333.77' Concrete Footings & Masonry Foundation (House Under Construction) ,33&8T t _ l J2„ Elit Fnd S 10037'40"E 366.05' .Total Hickory Hili Golf & Country Club Section 1 Map 1 PS 4 0 PG 105 '+�tqZ Z9C1'udrt ra. �% 'C'i (. •'' ai I declarey`tnat: l� cr 20 we surveiedlThr. pEn,tiY.'s'iwt�, this plot.: ,V t o. s c•^I--pg a;_x..55 9,7q� ie county envhealth 336 751 8786 P•2 i DEC 3Tt011 FOR Davie County Health Department fi SITE EVALUATIONlIMPROVFINFJVT PEitIiflT & ATC s �q F Env/1WMenta1ftea1thSeWon f _ P.O. Box 848/210 Hospital Street EN;/; r"'i' Mocksvillo, NC 27028 (336)751-8760 S ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED JJ INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. LI -1" Nemo to be Billed/ Contact Person U 1� L (/Nailing Address PO (7 6C3 Homo Phoma �---City/&tate/Z=P Business Phone p / c2�. Name on Permit/ATC if Different than Above -?cL23&x 9 S d hei%Q ^^�� Mailing Address City/State/rip —3: Application For: Bit valuation ❑ roVement Perms /ATC ❑ Both --.--System to service: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other ✓� If R.$idence: } People S�� } Bedrooms y } Bathrooms p�-- Dishwasher H Carbave Disposal WeW.. w Hachina (.1 basement/Plumbing 11 Basement/No P1Umbing 6. If Business/Industry/Othar: Specify type } Commodes } Showers } Urinals } People } Sinks } Hater Coolers Ir FOODSERVICE: # Seats ^ Estimated Water Usage (gallons per day) - 7-.- Type of water supply. County/City ❑ Well ❑ Community _,,a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes '00 O ifyes, what type? ***IMP0RTAN7*** IEK BELOW. Eith a PI A7 A L.' Property Dimensions: ar— ) Tax Otllee IN: S Property Address: RoadName C/ City/Zip/P/( 1PLETETIIE REQUIRED PROPERTY INFORMATION REQUESTED !STBESUBM17TEDbytbeclieat with THIS APPLICATION. TE DIRECTIONS (from Mocksvilie) to PROPERTY: 41 o�42 �I c Adm r �411- Ne d � t d If in a Subdivision provide jinffor/m�ation, as follows: Name: Section: ' ( Block: tc Property Flagged:�..�i4�_ 2M This is to certify that the information provided is correct to the best of my knowledge. 1 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. 1, also, understand that I am responsible for all charges 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 alltestingprocedures as necessary to determine the site suit /DATE Ior —� %--d (jSICNATURE G/ilil . THIS AREA MAYBE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locatious� Site Revisit Charge J a.N N Date(s): 7 V` tid Client Notification Date: EHS: y v " Account No. Revised DCHD (07/99) Invoice No. r e DEC -31-2002 TUE 01:53PN ID: �Q-t�P7"'• C -i `�.1% PAGE: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 - Q IMPROVEMENT/OPERATION PERMIT Account #: 990002566 Tax PIN/EH #: 5757-79-9833 Billed To: David Lee Subdivision Info: HickoryHill Lot#.. SaNiceh1l06rePj-4& Reference Name: Richard Hendricks Location/Address: Cedar Ridge Rd -27028 Proposed Facility: Residence Property Size: see map 1i6- 0dN- eia9O IU` ATC Number: 3375 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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 #People kT #Bedrooms -,? #Baths Dishwasher: e Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply /1 ( P Design Wastewater Flow (GPD) � Site: New � Repair ❑ System Specifications: Tank Size�4gb GAL. Pump Tank Other: Required Site Modifications/Conditions: 191-1 GAL. Trench Width Rock Depth Linear Ft.,3S 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.**** Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised)