204 Casa Bella Drive Lot 7iN
vPermit[ee's DAVIE COUNTY HEALTH DEPARTMENT
`Name y t � '~ Pr�E '. I ,, Ltrivironmental Health Section PROPERTY INFORMATION
f P.O. Box 848
Directions to property: `" ''I�}° t� t`` Mocksville, NC 27028 Subdivision Name: ` i t ' I V&t
Phone #: 336-751=8760
...1 Section: Lot: �O
AUTHORIZATION FOR
(� r
C. L WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 229-3 Z1 L. A Road Name: / !'� `!
�s"L�
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Countv 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.
(Incompliance Vith Art %1e 11 of G.S" C apter OA, Wastewater Systems, Section :1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENV-1RO E L EAH SPECIALIST �' DATA ISS ED
RESIDENTIAL SPECIFICATION: BUILDING TYPETI# BEDROOMS # BATHS �- # OCCUPANTS -� GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFr # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE (�� PE WATER SUPPLY ►� DESIGN WASTEWATER FLOW (GPD') NEW SITE - REPAIR SITE V
i 11' i
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH 1 LINEAR FT.
OTHER 1 J f(-1 V 1 IuJ f�yX.S
REQUIRED SITE MODIFICATIONS/CONDITIONS:
**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 (336)751-8760.
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 02/02 (Revised)
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DAVIE COEPARTMENT
COUNTY HEALTH D . .
'Nai e'• - -� �' �' s { Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
t
Directions taprope�y: .1 L ` `' `' `� Mocksville, NC 27028 Subdivision Name:
Phone #:
Section: E Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#,-,,
Y SYSTEM CONSTRUCTION -
;*
AUTHORIZATION NO: 2293- A Road Name:_G�C)t4
**NOTE** This Authorization for Wastewater System Constriction MUST BE ISSUED by the Davle� unyAArly�gm fta-'LIealth;$cction prior
to issuance of any Building Permits. This Form/Authorization Number should bepresented to the Davie County Building Inspections
Office when applying for Building.Pennits.
(In compliance with Article I I of G.SMfiapter'130A. Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
' ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
i IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIROP(MENTAL•HEAITH SPECIALIST DATE ISSUED
_ y
RESIDENTIAL SPECIFICATION: BUILDING TYPE L , 1' ` E q1 BEDROOMS # BATHS # OCCUPANTS / GARBAGE DISPOSAL: Yes or No
COMMERCIAL,; SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE V11 -TYPE WATER SUPPLY Wit= `� i �t DESIGN WASTEWATER FLOW (GPD) - l" NEW SITE_____ REPAIR SITE
II
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH_ ROCK DEPTH LINEAR FT. _
OTHER.,.
,.REQUIRED SITE MODIFICATIONS/CONDITIONS: i - � •�• `� �° '' � ��f �=-
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 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 02/02 (Revise
V
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
PO Box 848/210 Hospital Street
Mocksville, NC 27028
Phone: (336)751-8760 / Fax: (336)751-8786
February 10, 2004
Century 21
Swicegood, Wall and McDaniel Realtors
Attn: Mackie McDaniel
854 Valley Road
Mocksville, NC 27028
Re: Wastewater Certification Request -
204 Casa Bella Drive, Advance
Dear Client(s):
As requested, a representative from this office visited the above site January 23,
2004. The purpose of the visit was to determine the condition/sizing of the existing
septic system and if any modifications would be necessary to replace the existing
dwelling.
Based on our records and information provided on the On -Site Wastewater
Certification application, the existing system would have to be extended by 150 linear
feet to accommodate the new residence. The condition of the septic tank should also be
checked to verify that it has not deteriorated and if pumping is needed.
An Improvement Permit must be issued to allow the above changes. Please
contact this office if you wish to do so.
If you have any questions, feel free to contact this office at 751-8760.
Sincerely,
Jeff G. Beauchamp, R.S.
Environmental Health Section
(faxed)
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DAVIE COUNTY HEALTH DEPARTMENTtj
,_
Environmental Health Section _/
PO Box 848/210 Hospital Street
Mocksville, NC 27028
Phone: (336)751-8760
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMENT ❑ REMODELING ❑ RECONNECTION ❑
Name: /1 J Phone Number: / y ) - �� ,�j 1 (Home)
Mailing Address: (Work)
Detailed Directions To Site:
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Property
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2 i1 << c_
6� ; la/le -/'
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JOas- 64011
Please Fill In The Following Information About The Existing Dwelling:
Name System Installed Under: Type Of Dwelling:
C -i
Date System Installed(Month/Day/Year): Number Of Bedrooms.--3—Number Of People: ]�-
Is The Dwelling Currently Vacant? Yes Q--11ro ❑ If Yes, For How Long?
Any Known Problems? Yes 0 No 0--ff-Yes, Explain:
Please Fill In The Following Information About The New Dwelling:
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Type Of Dwelling: � Number Of Bedrooms: Number Of People:
Requested By
For Environmental Health Office Use Only
Approved 0 Disapproved 0
Requested:^
i11104 u�
r
Environmental Health Specialist ., Q --u- / .1.�-1 Date -"P
1 N
'Me signing of this form by the Environmental'Health Staff is in no way intended, nor should be taken as a I
guarantee(extended or limited) that the on-site wastewater system will function properly for any given period of time.
�/ as
Payment- Cash 0 Check 1? oney Order ❑ # �S I `f Amount- $ )0 0 Date:
Paid By: <Z:4 �4 c 4" Received By: U • -fir% �- ----f
r
Account #: 3 -t _- Invoice #: �� 3