107 Casa Bella Drive Lot 1;..;s r t9''w1 r ,-;. t _>r.>....*3"J - ".�-..c•rti-r -*.o
_DAVIE COUNTY HEALTH DEPARTMENT
t • tom, i ^ ''
;'_ IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permit
Subdivision Name: 111 t i-, C
'.Named
w�Directions to property: Section: Lot:
} IMPROVEMENT
PERMIT
-Tax Office PIN:# - -
Road Name t'�`!� I'' c.ta.�i Z. , f
**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 ] i of G.S.Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
j p� t ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
' ,. d '`,;�? ( PLANS OR THE INDED NTEUSE CHANGE. YOUR WASTEWATER
.,.ENVIRONMENTAL HEALTH SPECIALIST, DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
. INSTALLING THE SYSTEM:..
RESIDENTIAL
SPECIFICATION: BUILDING TYPE 1 r r1 # BEDROOMS # BATHS 1 # OCCUPANTS L4 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) NEW SITE REPAIR SITE
PIT-
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK - GAL. piENeeH WIDTH Wt ROCK DEPTH a„ LINEAR FT.
OTHER ' �1 *TQ-+(3JT10--,`
REQUIRED SITE MODIFICATIONS/CONDITIONS: J L.0yjF_a_ Y 1 T LAnT
**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 17"76"W.
W.
(336)751-8760
j'
. Ft's �.. \ �• � e ry
19
ON DAVIE COUNTY HEALTH DEPARTMENT
, IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittee's
Name: + �' ' 1 Subdivision Name. ' `3
Directions to property: Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#
Road Name:
!�`' 4 i t : � Zip:
**NOTE** This Improvement Permit DOES NOT authorize the construction of installation of aseptic 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
t PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAi,SPECIFICATION: BUILDING TYPE �' r ( #BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEtSHIFT f # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY'•, t ut DESIGN WASTEWATER FLOW (GPD) i s L NEW SITE REPAIR SITE
9
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRE1 WIDTH j-�' ROCK DEPTH LINEAR FT.
OTHER ( �.~,1 �::.��' l t —� F' x: `4_
•J _
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT.LAYOUT*PPPROI1ED EFFLUE14T'FILTER* *P.ISER(S) IF 6*' BELOW FINISIiEU GRADE*
•�--. Jr ln;,(,,:r ��{�/l�J�. "�1�1� � E..C,k'1.�1�t, � C�.�.r.:aC �1 i,`C�c4.. ►�.�
"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 (1W5 rf) y81U
(33&)751-07G4)
OPERATION PERMIT
SYSTEM INSTALLED BY:
T.
4
i
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 FORANY GIVEN PERIOD OF TIME.
DAVIE COUNTY HEALTH DEPARTMENT
Owner/Occupant LZ
Address UC4 C1_
SEPTIC YTNK PEPJ-1IT Date —/�—
To: $�
Address Aj
Building Contractor A40ress (( J /
eg
Cal. jj a Manufacturer's Name ` //� ddress
No. of lines / Width _,..�in. Total length S,S� ft. No. sq. ft.S_.
Type of filter material Total tons used a
Minimum REquirements: House Trailer Tank cap. 800 Sq. ft. line 400
Two-bedroom house 800 600
Three-bedroom house 900 900
No one shall install a septic tank in Davie County without a permit from the Health Offic
or his agent.
Date of Final Approval Signed:
Sanitarian
I hereby certify that the above septic tank has been installed according to specification
Signed
Se cTank Contractor
Note: Make sketch of disposal system on back of sheet and mail to Davie County Health
Center, Box 57, Mocksville, North Carolina 27028.
J. ��,1
APPLICATION FOR SRE EVALUATION/IMPROVEMENT PEI
Davie County Health Department
Envimnmenta/Hea/thSe on
P.O. Box 848/210 Hospital Street
Mockaville, NC 27028
(336)751-8760
AUG Z3
EidUIRO 1F f 11'ITY F LTH
13.5�C
***I1IPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS I1LL�TH REQUIRED �)
INVORIWION IS PROVIDED. Refer to the INSORMATION BULLETIN for instructions.
1. Name to be Billed Contact Persoa 3.62-PJ2— 2�
. � tp00r7
flailing Address ^/ �i% G'/1/�,o�-D,t�s Nome Phan. 9g6 " -6
city/state/SIP// w5e1 —e, AJ(I.;2 Business Phone
2. Nasse on Permit/ATC if Different than Above
Hailing Address City/state/sip
3. Application iror: ❑ Site Evaluation 0.1�provamsnt Permit/ATC ❑ Both
4. system to services ❑ Housebile Home ❑ Business ❑ Industry ❑ Other ••
s. If Residence: # People_ I Bedrooms _' # Bathrooms
O Dishwasher O Garbage Disposal Q Mashing Machine n Basonant/Plumbing 0 Bassmant/Ho Plumbing
S. If Business/industry/others speciry type
# Commodes
# showers
# urinals
# people # sinks
# water Coolers
Ir #'OODSERvICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: qty/City ❑ Well ❑ Community
a. Do you anticipate additions or expansions of the facility this system Is Intended to serve? ❑ Yes ❑ No
If yes, what type?
"""IMPORTANT""" CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBADTTED by the client with THIS APPLICATION.
Property Dimensions: �/ �iJl -�-% X00,[ lWRITE DIRECTIONS (from M«ksville),to PROPERTY:
Tax Office PIN: #
Property Address: Road Name%/d�s�t•.GC} �Y ,�e�v e�iD .�� o�iA.. �v pI'
Clty/Zip //elyt_ /1/2 , �,�L�� �� ���d �Y 44%P9�6�L
If to a Subdivision provl:ie Information, as follows:
Name: --)'0q ��
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 falsilled or changed I, also, understand that I am responsible for all charges Incurred frons
this applicattom I, hereby, give consent to the Authorized Representative oft if. e C Ith Department
to enter upon above described property located In Davie County and owned by s%
to conduct all testing procedures as necessary to determine the s to suits Ity.
DATE �' oZQ� SIGNATURE
THIS AREA MAYBE USED FOR DRAWING YOUR SITE PLAN (Incl de all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locatiolis).
Site Revisit Charge
Iv, LJDDate(a):
4p1) pr^ OO Client Notification Date
:
\ f ll lI9 EHS:
r% 00
- Account No.
10
Revised DCHD (07/99)'- Invoice No.
tq xce,
j x �a
?a
QUI NTA
EC. 155 N
10
P.B. 4 , 128
60
.3
30-
_i
DAVIE COUNTY, N.C.
TAX MAPS
SCALE' I"= 100
Davie County Health Department
4o?is _I� Environmental Health Section ,
P.O. Box 848
C�
210 Hospital Street
O 'C E C E 1 XfE Courier # : 09-40-06 1911
U
DEC o r 20 11 ocksvtlle, NC 27028
Phone: (336) - 753-678 b ON -SIT ASTEWATER CERTIFICATION Fax: (336) - 753-1680
( ec lacement Remodeling Reconnection
Name: /U7 Phone Number �' �� (Home)
Mailing Address: S-11- (Work)
6 00( Email Address:
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: ! a Type Of Facility:
Date System Installed (Month/Date/Year): / q,3 Number Of Bedrooms: Is Number Of People:
Is The Facility Currently Vacant? g No If Yes, For How Long?
Any Known Problems? Yes No If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
41
Type Of Facility: > 1A )� C/ x 41� Number Of Bedrooms: _Number of People (�
Pool Size: Ga age Si : Other:
n/ Requested By: ate Requested: `7--7-211
%� (Rion firrel
For Environmental Health Office Use Only
Approved Disapproved
Comments:
Environmental Health Specialist
Date:
*The signing of this form by the Environmental Health Waff 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:
Paid By: 4<1
Order #
Received By:
Account #: Invoice #:
I
Zer}DAVIE COUNTY HEALTH DEPARTMENT
/Occupant L;
/Address wa t
SEPTIC T K PERrtIT Date ��—/�_
To:
Address �
Building Contractor A Dress
(
Gal. d Manufacturer's Name r ddress
CD
No. of lines / Widthn. Total length ��,5ft. No. sq. ft.`S.-aC7
Type of filter material Total tons used 07
Minimum REquirements: House Trailer Tank cap. 800 Sq. ft. line 400
Two-bedroom house 800 600
Three-bedroom house 900 900
No one shall install a septic tank in Davie County without a permit from the Health Offi(
or his agent.
Date of Final Approval Signed:
Sanitarian
I hereby certify that the above septic tank has been installed according to specificatioT
Sign edL.,
Sepeld Tank Contractor
Note: Make sketch of disposal system on back of sheet and mail to Davie County Health
Center., Box 57, Mocksville, North Carolina 27028.
If yes, what type?
***1MP0RTANT*** CLIENTS MUST COMPLETE TIIE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions: -A-1- w) -27-V f/drh� —.:5"/
Tax OMce PIN: N
Property Address: Road Name /%�` �C.� sr
City/Zip ie 447yj
If in a Subdivision provide information, as follows:
Name: r �l
Section: Block: _ Lot:_
WRITE DIRECTIONS (from
gMockrAlle),t/o PROPERTY:
ehcgu4D le at. A,
Date Property Flagged:
This is to certify that the Information provided Is correct to the beat of my knowledge. I understand that any permit(s)
Issued hereafter are subject to suspension or revocation, if the Bite plane or Intended we change, or if the Information
submitted to 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 th e Countj#61th Department
to enter upon above described property located In Davie County and owned by z/
to conduct all testing procedures as necessary to determine the s to suits! Ity.
DATE ��D� SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Incl de all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
AL Tu )ZhATION Nt
Q: DAVIE COUNTY HEALTH DEPARTMENT
-.. f Environmental Health Section PROPERTY INFORMATION
Per m-iti6e til P.O. Box 848 , )
Name: f`�` r Mocksville, NC 27028 Subdivision Name:
Phone # 336-751-8760 K ��
Directions to property: Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION -
Road Na� O.ASA f +: LL k
**NOTE** This Authorization for Wastewater. System Construction MUST BE•ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building-Permim This Fonr /Authorization Number should be presented to the Davie County Building Inspections
Office when apply"ng for Building Permits.
(In compliance withArticle 1 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.
•E O1V ,E, tr HEALTH §PE IST DAT ISSU D
V
RESIDENTIAL SPECIFICATION: BUILDING TYPE #BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY (_,C' -1,,1V DESIGN WASTEWATER FLOW (GPD) Z , NEW SITE- REPAIR SITE
PI
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. -TILT Nee WIDTH �t ROCK DEPTH 1 LINEAR FT. f �
OTHER ( 'Dl�LF(jt
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT*RPPROVED EFFLUENT; FILTER* *RISER(s) IF 611 BELOW FINIBI- D GRADE*
2 11i E
i-r��►sr--------------
**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 (IM11634IM6W
(336)751-8760
OPERATION PERMIT
SYSTEM INSTALLED BY:
s'
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 " SEWA6�1`REATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY�FOR.#1NY GIVEN PERIOD OF TIME.
DCHD 05/96 (Revised) -
GoMaps GIS
Page 1 of 6
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http://maps.co.davie.nc.us/GoMaps/map/map.cfm?CFID=4129&CFTOY,EN=61640881 12/7/2011