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1060 Angell Rd ' r ; . � { � DAVIE COUNTY ENVIRONMENTAL HEALTH � P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 OPERATION PERMIT �c�our�t #: 990001502 �"�x Pl�€r'EH#: 5831-73-4648 Billcr�To: Mousavi Gen. Contractors Sut�c�i�ri aion I�f�: he€er�E�ce �ka�ie:: LacatianiAd+�r�ss: Angell Rd.-27028 f�ropc�s�sc9 F��:iEity: Residence �ro��rly Size: 63.08�Acres a�TC �Iurrtb�:r: 5110 **NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC 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. System Type:^�S.T.Manufacturer�C� Tank Date � Tank Size (i�Od Pump Tank Size System Installed By:�fG�h.S�Lly' �1C�6h�—• E.H. Specialist: b�LW�. �'G'�ate: aa11Z GPS Coordinate: ?r�^��-.' � --- -----__� ---------....._ � �� • ,. �--iS=sIS ,�;c, � ��53 � ti �� ` � 3'x�� e�,��, �'' < z��--a . — ��`', /� . DCHD 11/06(Revised) , •- DAVIE COUNTY ENVIRONMENTAL HEALTH ,.. �, P.O.Box 848/210 Hospital Street , � � Mo�ksville�NC 27028 (336)753-6780/Fax#(336)753-1680 AUTAORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION f�cc�u�t #: 990001502 � . T�x Plf�i�H#: 5831-73-4648 ... Biiled To: Mousavi Gen. Contractors : ; Sut�di�i�ion 1ri�o: �('�� . . }��fe�-�r�ce P�an�e:: :.: LacalionrAddr�� An -27028 i . . t�ro�c�s�c� F��:i€ity: Residence .� , P�o�� ❑16�A$�' : �TC N umber;5��(� �' i�r �Expansion - ��j��-Thi�}�orization to Construct(ATC)MUST$E ISSUED by the Davie County Environmental , , . . Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A Wastewater Systems, Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. Residential Specifications: #Bedrooms�_#Bathrooms 3 #People�Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size � � �.L , Type of Water Supply: ❑County/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD)��Tank Size�� GAL.Pump Tank��GAL. Trench Width� Max.Trench Depth 3t�,,. Rock Depth� Linear Ft.,53�, CUnUI'(1�k"��-� Site Modifications/Conditions/Other: yF,lp' ��(�� Contact the Davie County Environmental Health Section for final inspection of this system between 8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760. � � s `f \�'� C . � �� o - � Environmental Health Specialis Date: /D �� Z�� DCHD 11/06(Revised) ��(S�� ; � , . . Davie County Environmental Health P.O.Box 848/210 Hospital Street . Mocksville,NC 27028 (336)?53-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Account #: 990001502 Tax PIN/EH#: 5831-73-4648 Billed To: Mousavi Gen. Contractors Subdivision Info: Address: P.O. Box 5983 Location/Address: Angell Rd.-27028 City: Winston Salem Property Size: 63.08 Acres Reference Name: Propo*NOTE*�t*�ThR I peovement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. Permit Type: Cr�New ❑Repair ❑Expansion Permit Valid for: ❑5 Years ❑No Expiration Residential Specifications: #Bedrooms � #Bathrooms�#People �I Basement� Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) �� Design Flow(GPD):u�o Type of�Vater Supply: ❑County/City f�'rWell ❑Community Well � Site Modifications/Permit Conditions:. S stem T e LTAR Initial 6A e� '�v Re air Site Plan , � ` ' ��/ � �� Environmental Health Specialist � Date , � i.p.l 1-06 , �' ► � DAVIE COUNTY ENVIRONMENTAL HEALTH • ' P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Acc�u�t �: 990001502 '��x PI�€iEH#: 5831-73-4648 Bific� To: Mousavi Gen..Contractors �u�divi:.,iar� In�o: f��Fer�r�ce P�a��: LocaiioniAd�r�ss: Angell Rd.-27028 E�ro�o��i9 ��a�:i€ity: Residence �ro��r�y �iz�: 63.08 Acres a�TC h�turYtb+�r: 5110 Site Type: ❑New ❑Repair ❑Expansion **NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. Residential Specifications: #Bedrooms �'� #Bathrooms�#People L� Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size��` Type of Water Supply: ❑County/City ,�1.We11 ❑Community Well System Specifications: Design Wastewater Flow(GPD)�Tank Size/��GAL.Pump Tank lv GAL. Trench Width�� Max.Trench Depth " Rock Depth /2'" Linear Ft.S�3'Lbn�tn�(/ Site Modifications/Conditions/Other: �� Fal�G�t�A Contact the Davie County Environmental Health Section for final inspection of this system between 8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760. 1�� \. : �aYy� �� =`� �. - �.`. I�fU� o -y-` _ �_�t , Yi'&'._, )/ _ �r�, ,��'� �ay�' � � , __,____. I I � �L;E.� � I � �...._ �� ._._,�'_ Environmental Health Specialist Date: a Q ��/C� DCHD 11/06(Revised) . - �, ' ' . • ' Davie County Environmental Health P.O.Box 848/210 Hospital Strect Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Account #: 990001502 Tax PIN/EH#: 5831-73-4648 Billed To: Mousavi Gen. Contractors Subdivision Info: Address: P.O. Box 5983 Location/Address: Angell Rd.-27028 City: Winston Salem Property Size: 63.08 Acres Reference Name: Proposed Facility: Residence **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. .__._.___._..__.___.._..____._._._._�..__ . ___ ...____.----__.__..�_.,___�._ _._._. . ___... . ._ __ __._. .. ... _ _ . _ Permit Type: I�.New ❑Repair ❑Expansion Permit Valid for: �'S Years ❑No Expiration Residential Specifications: #Bedrooms y #Bathrooms�#People �� Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): '7�� Type of Water Supply: ❑County/City �Vell ❑Community Well Site Modifications/Permit Conditions: System T e LTAR Initial c� � �¢�,u Re air n Q � Site Plan f--- �/_� � � 0 F� / ('�• y ��/�; � � 1 ��o � ��Q� '� �,� �, ��',. Environmental Health Specialist Date �� v i.p.l l-06 . ,. �--- �'�' � � ; �2�1 '� �PPLI (�� ,� , EVALUATION/IMPROVEMENT PERMIT & ATC $ � � � `'�Da ie Coun Environmental Health �� ,� O.Boz 848/210 Hospital Street ' ,-�� G 2 3 �.�14 Mocksviiie,rrc Z�o2s � ` A � (3 6)753-6780/Fax(336)753-1680 �� ,;��Zt1 Applicatio�For: �tfi�tion/I�npr�o�ve Permit ❑ Authorization To Construct(ATC) ❑ Both Type of Ap lication: ` �"�em-�fZepair to Existing System ❑Expansion/Modification of Existing System or Facility **''IMPORTAN7*'�*THIS A.PPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name mnt,l,5 czV i �.ey�2�Ca� ��..��aC'�+�,�„�' Contact Person �I�� VYl o�a.�? Address Home Phone �3 (- 9 ii�- � � �'�' City/State/ W `�� - S��,M,n��_�aT/�� Business Phone 3 3�_ �f e�t,�q 2 6' Name on PermidATC if D�erent than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facili Corners Fla ed NOTE: A survey plat or site plan must accompany this application. Included: 0 Site Plan OPlat(to scale) (Permit is valid f�'60 months with site lan,no expiration with co,�m'lete lat.) Owner's Name �/�_ ry►nc,�5c�J'r �l�/i 1�i A cM �hJ��(I �ru5-� Phone Number Sa.�„p Owner's Address S v,v� City/State/Zip Properiy Address � �1 q A City r, - Lot Size �3- ��'�C Tax PIN# SA3I-�3- ��c� Subdivision Name(if applicable) Se tion/L,o D' ections Site: C /N 0 /l' l!V % 6 N � � � D S If the answer to any o the fo lowing ques ions i "Yes",supporting docum�e tation must be attached: Are there any existing wastewater systems on the site? Yes ✓No Dces the site contain jurisdictional wetlands? _Yes No Are there any easements or right-of-ways on the site? Yes �o Is the site subject to approval by another public agency? Yes vP�"o Will wastewater other than domestic sewage be generated? Yes No IF RESIDENCE FILL OUT THE BOX BELOW , #People �_ #Bedrooms _� #Bathrooms � Garden Tub/Whirlpool �.(Yes ❑No Basement: ❑Yes No Basement Plumbing: ❑Yes o IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals� Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested: �Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water [�1ew Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? � Yes �No If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my Imowledge. I understand that any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or sa�:ing the hytu ility location,proposed well location and the locarion of any other amenities. S E�—�–� Site Revisit Charge Property owner's or owner's legal representative signature Date(s): � �� o�.�� Client Notification Date: Date EHS: Sign given ❑Yes �No Account# 5�Z Revised 11/06 Invoice# _� ' �� ' . �- — .` � � . . ^ : r , _ � � _ .� <.,�T��T ru2 ser�r n+e etise oF�r � ANGEI.L L SEf AT THE Bi.E OF�BENi TALI AXLE Fd.M�7HE CORNFR ~ � "� ' (S.R. 14E LONG AU(E Fd,hIE N.W.CORNER y, � �� -�_ �� V•�'' OF W�RE FENCq7HE N.E.CORNER �� i JOHN H.ANCIIl MID WIF'E CYMA 1 OF TRACT lA ON PB.�,PG.1 S7 - , �. � . ;ELL'S PROPERPf,SEE DB.66 A7 � • � �� ;E 214 � � ' ^— cac� \ t NOW OR FORMEKLY �cK� � � ' JOHN H. ANGELL w�",�CLARA ANGELL ' � S 02°30'46"W 230_60' ��RE� � DEED BOOK 66,PAGE 2t4 ��p��.�� (l1E UNE} j 0 !S�7 p� . PIRCEL I F400D00049 - O �� O� ` / � S �ME p��N�s (SEE PUT BOOK 3.PAGE 117) � �iE'� . 'I_ ^ d ` lSoo �� . . �(.� .i,�� S � Q'QQirw `. , �� "�� "�""f�N � 1) 2�0 �� O /� � .7� . . 00_46' O'��,�^. ,Rfp_V�!� � . i � �t7, z 1��oJE ��y� � �'"SUALL ..., k2��~_>��eF27w4 SET • . � . O � �� fII+CE CPOSSES iNE P/L f�T oF r� �� fm'� � $ !�� NERE a/- �E A�6V hIISM[,� • �x 784.76�(TOTAu . y � N 1 S �5� 49��W�-s e � � � 3 � NEW TRACT 1 WL OF 40��sr¢r cuu�,n.J� 'ao.o • s.is�g, y r ��*�eV1La�+� s 63.08 ACRES CORNER BETWEEH 7WCf5 1A h h „r• � Q ,S,�os oN�o�,�sUo / . � � J/4"IRON%PE RESET TO � 25 SHOWN ON OLD PUT BOOK J, *p �°O��O��W f(HO E'1CFOACMYENTS) I / RE UCETHE MISSiHG N.W.C�RNER PMaE 117.SHOWING TNE�NISI�N OT 't� � J VG'UV�UV'�C"� ' O� tA Of PB.3.PG.117 ��E��ife 4viY M. �y��`� I OJ.tyU� �Q . a t 496.32' , z� �nNY PND nLL RICHT(S)-OF-WAY AND (A NEw PROPEmr uNE7 �R W�Y NOT BE OF RECOtiD AS OF THE -~N �5�2T�}J'�E '1 6 - � � R� M0.76� o�., S O, Y NOT BE VISIBLE UPON THE GROUND. f"u rros w��E rs 5 27' `�'M a/Z�.�t/� �j� 3I4��iaon PiPe rt�sEr • A= 306.34� �� Q.� : :E FOR THIS PROPERTY SEF CEE�900K �Sr�TNE P/U --�` V � �4�3.3�t�.9�� cOR�NEPRUCEIHE M1551NC S 66•te'�aST��SW.21' e. �In sPiw-c E 1559.8p� 2 /w THE 0.0N a0 DEED BK. 136, FG. 299 ' � ' N 00°14'72"W 1139.52� v �-$ ��. {�W.1N5 YnRE f[N�5 W[y7 OF TI�E '_ 'TRACTIAOFTHEOMSIONOFJ.H. ------ ------ - .F� f M.ANGEIl PROPERiI'.RECORDE�1N r iRON Fd.wrtH i.o.r�.a n� =y",,:i- ' �� 7�85.40'�---ioo° ��s�4N1�� 10 ` ��^ � MID OATED DECEMBEF? 1961. iHE N.E CORNEA Of�taiES Of A id nONE L-4 ,�( JA1�S L.TIJ1TEROlI NOW OR FOR4ERL7 L NfTEROW'S PROPERtt - SfY DB.1 ffi.PG.4eB �� ' urt m rouR THE PA'�C�!ENT OFANGELL ROAO D_AHLGREN E. UPDEGRAFF� FRANCES 1/.TURTEROIf I �J� � _S UNLESS NGTEO Of}itRN1;;E. : DEED BOOK 186,PAGE 740 � . - o�n BoaK nt,P�ce 987 '� v�,�� ; �-- ..+prR�{E�IOOOOo0�3 PMCEL j F400000(7510J �,. . . " FROM DAVIE COUNTY SUBOIVISION , JAMES L. TL'TTEROF—1 L_2 f G.�,.oar� �` MJD WItF�... .1T7.q� 1 :H NEW TRACT IS OVER TEN ACRES iN � FRANCES lf. T1i1TEROlf � r �R°"�� s a�""' V9]• E�MII�S£(DI D�BUOK 671,PAGE 104 � MRmuC�t _ E—�E� ONUMENTS WERE FOUND V/ITHIN ' P"Rc�'�£4°°°°°o��oi . �-� --___""" � �� ,�-,..� ' N 03°53'51 'ERTY. � -- JAMES L. TU2TEROlP � - -- t `R�^� � 446.00'l� �R_q � ,wo vn� � s earoi�rE 100. � FRANCES 1f. TUTTER0�1� � ROLAND H. IiEST, dR. ��. ,r��E,r� DE£D BOOK 182,PAGE 488 4 � OEED BOOK 192.PAGE 333 - s FAftCEL j E4000000J2.07 � PARCEL/EIQ^COp�32 . I PATRICIA�L. HOWARD ��AYETT: I - � OEED BOOK 149,PACE 4B7-A � � PMCEL+�F400000051.01 BF'T�, DEED BOOK � PAR�EL� � CALL TABLE ALONG i20AD COURSE BEARIN� DISTANCE L-t S 85°56'46"E 64.56' L-2 S 85°57'42"E 53.76' L-3 S 86°45'45"E 202.19' ' L-4 S 85"41'06"E 1 U4.14' 300 0 30U L-5 S 82"36'55"E 21.72' -- rrrnTri- ` _, GRAPHIC SCAL£ - FEET �.��..•..,... .�'�,�Y;�_ '� i,naw.n v-c oxvm�+c a+ortss�aw.w+o suw�on A DMSI :GENO 1.RONAIl1 LEE OXENDINE,CERTFY THAT TIi1S PUT WAS DRAWN UNDFR :. '1i^�.'� ,,.M,/0. �-�057. CERTIFY TO ONE OR WRE an+c raiar+ho = �7�� MY DIRECT SUPERVISION FAOU AN AC1Ua1 SUf7VE1'MVDE UNDER Ml' ` �� -� • �� : 1�S.�• THE SUPVEY[RE�TFS A SVBDIVISIq1 OF LANO IN AN WILLTAM W. tu�G PROPEflY7 LIHE �� ARE�COYERED OY A SUlOIV1311N ONDINNICE. ApI01NINC UNES(NOT SURvEYE�) 0lRECT SUPET/1StON(DEED DFSCR1Pfi0N RECARDEU M BOOK j� ' ' TOTAL AREA OF THE DMSiOM IS 73.76 ACRE' /�� ❑2. 771E SUNYEV IS OF lU1D IN AM VMREGVlATEO ME�. r �,... . UNOERGROUND 0.ECIR:GL L1NE PACE :EfC.I(0'MER):TUT 7HE BOVNDARIES NOT SUR�f�EO �'�d� '� ` /,��=C'._ � _.__. 7RAC7 tn r,ECO�oED w OLQ � . �. . •_• • � DAVIE COIJNTY HEALTH DEPARTMENT � . � Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001502 Tax PIN/EH#: 5831-73-4648 Billed To: Mousavi Gen. Contractors Subdivision Info: Reference Name: Location/Address: Angell Rd.-27028 Proposed Facility: Residence Property Size: 63.08 Acres Date Evaluated: ��`� Water Supply: On-Site Well �- Community Public Evaluation By: Auger Boring Pit Cut FAC'TORS 1 2 3 4 5 6 7 Landsca e position Slope % � c� c„ •,, HORIZON I DEPTH Texture grou Consistence Structure Mineralo i�;� ; (, HORIZON II DEPTH � . y Texture rou � Consistence Structure , k Mineralo 1; 1 ( ' HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence S tructure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: � EVALUATION BY: � LONG-TERM ACCEPTANCE RATE: `� OTHER(S)PRESENT: REMARKS: LEGEND T.�ndscape Position R-Ridge S -Shoulder L-Linear slope FS -Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Fiood plain H-Head slope TgxtllTg 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 . CONSIST+N . . �'IQ1St VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm � NS -Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky � NP-Non plastic SP- Slightly plastic P-Plastic VP-Very plastic StrLct�re SC -Single grain M -Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralo�v 1:1,2:1,Mixed 1YQSs� 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) TTAR _T.�...o_rP.�„ �r.�A..to.,.-o��re ....1/.t..../t«'� — `--- - ' ■�■��■�■��■■��■�■�■�■��■��■��■■��■�■�■��■ ■��■��■��■■/�■��■��■�■��■��■■��■��■ ■��■��■ ■��■��■��■ ■/��■ ■��■��■��■�■��■ ■�■��■■��■■��■�■��■��■�■■■��■��■��■��■ ■■�■��■��■��■��■��■��■ ■��■��■�■��■��■�■■s�o��■■��■��o�■��■��■��■ ■��■��■��■��■��■��■��■��■�■��■ ■��■��■��■��■��■�■��■��■�■ ■�■��■��o��■ ■��■ ■��■��■��■��t��■��■��■ ■��■��■��■�fii��■��o��■ ■��■��[I��Ir��■��■��■��t�■ ■��■■��r��■��o■��A��i��■��■��■��■��■ ■�■��■�■��■��i��■��:i��i��■��■ ■�■��■�■��■��■��n�i��■��■��■��■ ■��;�a��h��o��■��■ ■��■��■��■�� ■��id�■��sa��■��■ ■��■��11■�� ■��Ili��I��r��■ ■��■��■��11■�■�■■��■IAF.ii7��l��i�111lJr7�■��■ ■��/��\��il��/��UI'�:I��I��f�li�iil11i1��■ ■��/��■��11��:_;:.:�I��■ ■�■��l��■��■��11�■��■��■/■��t�t1/I■��■��■��■��■ ■��■��11��■��■��t��■ ■��■�■��■�11�■�■��■��■��1��■��■��■�■ ■��■��11��■��■ ■�■�1■��■��■��\��■ ■��■��11��■■��1��5��■��■��■ ■��/��■��11��1��■ ■��■■��■��11■�■��■��/��II�■��■■��■��■ ■��■��11��■��■■��I1��/��■��■ ■��■��■��■��11��■��1��/��0��■ ■��■��■��0��11��■��■fl��■■��\��■ ■��■\��11�■��■■��11�■��i�■��■��■■��■■ ■��■■��11��■ ■��11■��■��■�■ ■��/i��11��■��11��/��/��■ ■��■��■��11��■�■■��■■11■■��■��■��■��■■■��■ ■��■��■■��■��11��■��Il��i�■��■��■ ■��■��■�e��■��11�■■�■�■■�■��11��■■�■��■��■ ■��I1��11��■ e�■��■��■��■��■■��■��■��■ �iiiiii�iiiiii�iiiiiiiii�iiiiii�iiiiiii�iiiiii�iiiiiii�iiiiiii� ■�■�■■��t��i��■�■��■��■��■��■��■■�■��■��■ ■�■��■��■��■��■��■��■��■��■■��■ ■��■��n��■��■��■vv��■��■��■��■ ■��u��■ ■��■�■��i��■�■■■�■��■��n��■��■��■��■��■��■�■ ■��■�■�■��■�■��■■�n��■��n■��■��■��■�■�■��■��■ ■��e��i��■��■ ■■■■��■��I��■ ■��H��■ ■��■�■��1��■■��!1i��fi��■��■�e��■��■ ■��■��■��I��■�i��■\�■��/��■��■ ■��■��/��/��I��/��IS■/��■\��/��/�■/■ ■�■��■��■��i��■■��ei��■��■��■��■��■ ■■��■��■��i��■��i��■��■ ■��■�■i��■�■��■�!■��■��■��■��■��■��■ iiiiiiiiiiiiiiiiiiiii�::::e��ii��■ e__d� ■��■��■��■■��■�■ ■��■��■��■�■��■��r��i��Ri��n r��t��■��■��■ ■��:��..�.��,s„�-:�a,:��■ ■��■��■�r�r��■i��i��■��■��■��■��■��■��■ ■��■��:ISliii��r��■��■■�■��■ ■��■■��■��■��i��■�■■��■��■��■��■ ■■��/��/�/��/��■��■ ■��■ ■��■ ■��■■�■��■�■��■�■��■��■ ■■■��■��■■�■��■��■��■/■��/�■ ■�■��■��■��■��■��■�■ ■��■��■��■■��■�■��■�■■�■■■��■�■��■��■��■ ■�■��■��■■ ■��■ ■��■��■��■��■ ■��■��■�■��■ ■��■��■��■��■��■■■��■■��■��■��■��■�■ ■��/■��■��■■��■��■��■��■ ■/�/��■��■��■ ■��■�/��■��■��■��■�■��■��■ ■��■��■■��■��■��/�■��■��■��■��■�■��■ ��/��/��/��■ ■��■��■��/��■��■��■��■��■�■��■ ■��■�■��■ ■��/��■��■��■�/��■ ■��■��■��■�■��■��■��■�■��■�■ ■��\��■��/��■��■ ■�■��■��■��■��■��■��\��■��■��■ ` . `, � • . Davie County Health Department ��is j� Environmental Health Section � . , .� � "� P.O. Box 848 . ' C� �'" , ,�, 210 Hospital Street ' � O� �'t Courier# : 09-40-06 "• 1911 Mocksville, NC 27028 Plione:(336)-753-6780 ON-SITE WASTEWATER CERTIFICATION Fax:(336)-753-1680 (Check One) Replacement Remodeling Reconnection Name: (,�5 V/ Phone Number (Home) Mailing Address: �V. (}JC 5g� � `�q� (Work) ��, /vC 7�� Email Address: Detailed Directions To Site: Property Address: Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: Q'r ��"I�/�-e� �S d� �//T��Of Facility: , �� Date System Installed(Month/Date/Year): 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: Please Fill In The Following Information bout The NEW Facility: �., Type Of Facility:`s�� (' ��`''i�1 ,�X2/'� Number Of Bedrooms:_��Number of People_��7 Pool�ize: Garage Size: Other: Requested By: Date Requested: D 3- l��- �Z (S gnatur � For Environmental Health Office Use Only Appro Disapproved Comments: Environmental Health Specialist i� Date: c�f�/ *The signing of this form by the Environmental Health Staff i 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 Check Money Order # Amount:$ Date: Paid By: Received By: Account#: Invoice#: . } . 4 , � - . .. .. . . , . , . , � �/ � Y.� 1 ' r_�h. .-� � .. •c, : y ..d. �T � � ' Davie County Health Department V � ��;8 Ic� Environmental Health Section � : .. , - '�� +` P.O. Box 848 . • � ` ~ ,�"�,�, 210 Hospital Street � ,- (� _ O U �'�. Courier# : 09-40-06 1911 Mocksville, NC 27028 � Phone:(336)-753-6780 ON-SITE WASTEWATER CERTIFICATION F�:(33s>-�5�-l�so (Check One) Replacement Remodeling Reconnection • � Name: � J� �l Phone Number (Home) � Mailing Address: . ��. ��C � " 63 �7��U (Work) �•. � �G �,.�I�3 Email Address: Detailed Directions To Site: Property Address: Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: �� 5��I�� f I S �1 �/��p�Of Facility: Q�.�i • Date System Installed(Month/Date/Year): Number Of Bedrooms:�Number Of People:�_ Is The Facility Currently,Vacant? Yes No If Yes,For How Long? Any Known Problems? Ye� No If Yes,Explain: Please Fill In The Following Information bout The NEW Facility: � 1 �/ ,r�� E-iv Type Of Facility:'S7�R�`? L ��!`��N ��'Z�� Number Of Bedrooms: ��=�`Number of People �� Pool Size: Garage Size: Other: Requested By: S�- ,� � Date Requested: f� 3— ��-- �2 (S gnatur ` For Environmental Health Office Use Only Appr� Disapproved ;omments: Environmental Health Specialist (,�) �.� �, i . ', F Date:.�� .`) %a��/ ; *The signing of this form by the Environmental Health Staff i�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 Check Money Order # Amount:$ Date: Paid By: Received By: Account#: Invoice#: y�; . , r . . . . i u:* " � Davie County Environmental Health x'" P.O.Box 848/210 Hospital Street Mocksville, NC 27028 � (336)753-6780/Fax(336)753-1680 �� IMPROVEMENT PERMIT Account #: 990001502 Tax PIN/EH#: 5831-73-4648 Billed To: Mousavi Gen. Contractors Subdivision Info: Address: P.O. Box 5983 Location/Address: Angell Rd.-27028 City: Winston Salem Property Size: 63.08 Acres Reference Name: Proposed Facility: Residence **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater systein. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. ..._._.__.__.__�______.____.__.__._.. __.._.._._..._......___....__.__.____..___ . ..... .._ . . __ ._. Permit Type: �.A1ew ❑Repair OExpansion Permit Valid for: �5 Years ONo Expiration Residential Specifications: #Bedrooms y #Bathrooms�#People �� Basement❑ Basement plumbing� Non-Residential Specifications: Facility Type #People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): �� Type of Water Supply: ❑County/City [�Well ❑Community Well Site Modifications/Permit Conditions: System T e LTAR Initial � � ,�� Re air R e �i Site Plan F----- �/�:� - \ �o � N� �"'`� O �- �in�� 3� y �r�� ,� ��-�' '�, "� �o � ��. � � Environmental Health Specialist Date /� 2� � i.p.l l-06