238 Armsworthy Rd HEALTH DEPARTMENT RELEASE For-Office use Only,
FIle Number .,139501 -1
«Ao Davie County Health Department
f 210 Hospital Street County1l)Number.
P.O.Box 848
Evaluated F6r:r. /WWC
Mocksville NC 27028
Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID 0 7 / 1 5 / .2 0 1 9
UNTIL:
Applicant: Hattie McCulloh/Jerry Property Owner. Hattie McCulloh/Jerry
Address: 4662 US Hwy 158 Address: 4662 US Hwy 158
City: Advance City: Advance
State/Zip: NC 27006 State0p: NC 27006
Phone#: (704)467-5038 Phone#: (704)467-5038
Property Location& Site Information
Address238 Armsworthy Road Subdivision: Phase: Lot:
Road# Advance NC 27006
SINGLE FAMILY Township:
'Structure: Directions
#of Bedrooms: 3 #of People: hwy 158 East Armsworthy Road on right,before Baltimore Rd.
'Water Supply: PUBLIC
Basement: n Yes n No Type of Business:
Total sq. Footage: No. Of Employees:
'Proposed Improvement:
Replace SWMH
'Release Conditions
7;
This release inno 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/Legalkeps.Signature Required? Oyes ONo
Applicant/Legal Reps.Signature: _ *Date:
*Issued By: . 2140-Nations.Robert *Date of Issue: 0 7 1 5 a 0 1 4
Authorized State Agent: �J/1/
**Site Plan/Drawing attached.**
HEALTH DEPARTMENT RELEASE 139501 - 1
1 Davie County Health Department CDP File Number:
210 Hospital Street
_ P.O. Box 848 County File Number:
l Mocksville NC 27028 Date: 0 7 / 1 5 / 2 0 1 4
Ivy
O Inch. .
Scale: OBlock .ft.
Drawing Type: Health Department Release ON/A
/�p�✓1'f6; S�c '�a a c Sr0o;V/c,
Page 2 of 2
Davie County Health Department
�6j Environmental Health Section
P.O. Box 848
210 Hospital Street
D Courier# : 09-40-06
U PA Mocksville, NC 27028
Dani
Phone:(336)-75 - Fax:(336)-753-1680
e :
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Name: k4i,5 �eC�c��l Phone Number '/O( 407-5039 U _(Home)
Mailing Address:. Z US 11PV l (Work)
Q C Email Address:
Detailed Directions To Site:2 r 15V QQ 10!j h't' f,/' ��/rt°
Property Address: SG(/(j l v lei
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: d fi Type Of Faci '
Date System Installed(Month/Date/Year): f 7i Number Of Bedrooms: Number Of People.-
Is
eople:Is The Facility Currently Vacant? Yes No If Yes,For How Long?
Any Known Problems? Yes If Yes,Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: /n 14 Number Of Bedrooms: Number of People
Pool Size: Garage Size: Other:
equested BLLignjwe�
ate Requested:
For Environmental Health Office Use Only
Approved Disapproved
Environmental Health Specialist Date:
*Thesigning 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.
Paymen Cas Check Money Order # Amount:$A 6 0 0 Date: A L/
Paid By: / C(r[tia l Received By:
Account#: Invoice#:
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Printed:Jun 24, 2014
All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the implied
warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie,
North Carolina,its agents,consultants,contractors or employees from any and all claims or causes of action due to or arising out of the use or
inability to use the GIS data provided by this website.
NX 70
r �
CD2
IMPROVEMENT PERMIT
Davie County Health Department
210 Hospital Street CDP File Number: 138827- 1
f� ox 848 L40-000-0025
Mocksville C 27028 County File Number:
Date: 06 / 23 / .2014
Click below to import an image from an external loc on: Drawing Type: ovement Permit
Page 3 of 3 P1 P2
DAVIE COUNTY HEALTH DEPARTMENT
Names " (°L� Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property: ! 5 0 Mocksville,NC 27028 Subdivision Name:
10 /1 1 ,y,S �� G� � ►�Y G.( Phone#:336-751-8760
Section: Lot:
J / AUTHORIZATION FOR
r (pr /E WASTEWATER
" Tax Offise PIN:
SYSTEM CONSTRUCTION
i
AUTHORIZATION NO: 002923 1� - Road Namef ,5 W Zip:
%
**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 co m liance 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_, S&IN
,�
RESIDENTIAL SPECIFICATION:BUILDING TYPE 1J11 #BEDROOMS #BATHS ( #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATIO14: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
t, d t✓-e
LOT SIZE 1 TYPE WATER SUPPLY Ca ' DESIGN WASTEWATER FLOW(GPD) Vl U NEW SITE REPAIR SITE ✓
Cif
07
SYSTEM
4,
SYSTEM SPECIFICATIONS: TANK SIZE "''x GAL. PUMP TANK—�_`-„"L. TRENCH WIDTH ROCK DEPTH LINEAR FT. ( U
OTHER
/,,s stated in 15A N C C 18A.1963(5)
REQUIRED SITE MODIFICATIONS/CONDITIONS: me apted Systems may also be usG
IMPROVEMENT PERMIT LAYOUT (�
C, 51
" To �ra.�� i �I G u k G c��( o�� 1�7 . / � u , �' C�� lep Le -e
S W M N ,. - (� U 61 S o u s ct b -�
f
i
t L-00 -lh 0 n,
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY: E (_e
v 1
AUTHORIZATION NO. ERATION PERMIT BY: TE:
**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.`
DMD OM(Revised) lqeter -475-2 q`i TA)U
,h•, 1 , r.w4 -
P cmiuee.$ } DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
P.O. Box 848 J
Directions to property: / r Mocksville,NC 27028 Subdivision Name: 1
C. 6" Phone#:336-751-8760
� Section: Lot:
` 1 AUTHORIZATION FOR
r �� M ;\ i C .* It WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN:#
AUTHORIZATION NO: 002923 A RoadVame: Zip:
**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 ForrrJAuthorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 1 I 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 ISM Aoga i l
RESIDENTIAL SPECIFICATION:BUILDING TYPE lrV #BEDROOMS BATHS #OCCUPANTS! GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPEfIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE l TYPE WATER SUPPLY Co ' DESIGN WASTEWATER FLOW(GPD) �t u NEW SITE REPAIR SITE ✓
SYSTEM SPECIFICATIONS: TANK SIZE r'r GAL.PUMP TANK—.AZ/ L. TRENCH WID H '3G ROCK DEPTH Cr LINEAR FT. /
OTHER
a:
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
:�`'.� k (5� c •L stj
)� F c LA ( 5 �1 +C`7� 't> -L. k (D I O C
LX
r'� Gam,'
�V Tpi )1I-Fi-jzvz.J0rt 044c p��� �,r;'� . � y 0 ,
G.6 V1-r--e-d e-d
suv M N
r r �
i
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
a F—
' OPERATION PERMIT
}- ►. SYSTEM INSTALLED BY: rY'
Mq
AUTHORIZATION NO. �4 �'�QERATIONPERMITBY:--;;-�� TE:=., •-.
**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.
DMD 01102(Revised)
til[A JM fll-Wdf h 1
• DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION yYt� NI
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) '7
NAME inj ��/!6 PHONE NUMBER 67� 07b%a
ADDRESS &/ S 14VPgf=sUBDIVISIOON NAME
LOT#
DIRECTIONS TO SITE Nd6 2
�j�am' ���
DATE SYSTEM INSTALLED ` NAME SYSTEM INSTALLED ADgER�ry /1 "1/D-'I
TYPE FACILITY .SW M H NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING�7 %( hAle,
b&t;M4 14n "Od(
DATE REQUESTED '2-�60 - INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge,and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT a
Rev.1/93 k68'��
Q 5'S� V✓ � EGc�i 6-� S� S�`�it
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