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978 Baileys Chapel Rd � I-IEALTH DEPARTMENT RELEASE Foro�ceuseon�v � 'CDP File Number 157891 - 1 �a.,��o Davie County Health DepartmAq��� ia-000-oo-oss ""....,, i ,��¢ 210 Hospital Street E� + �1v �� County ID Number: �`� . � � P.O. Box 848 ���e�, �/[ Evaluated For: HDR/V1/WC ' �"'� Mocksville C 27028 �,�.�.�,.� Phone:336-753-6780 Fax:336-753-1680 PERt�11T VALIO � g / 1 0 / a 0 1 9 U NTI L: Applicant: Beth W Fordham-Meier 8� Mark Property Owner: Beth W Fordham-Meier& Mark . eier . eier Address: 978 Baileys Chapel Rd Address: 978 Baileys Chapel Rd ���Y: Advance C��Y: Advance State2ip: NC 27006 State2ip: NC 27006 Phone#: �336) 998-5682 Phone#: (336) 998-5682 Property Location 8 Slte Iniormation Address978 Baileys Chapel Road Subdivision: Phase: Lot: Road# Advance NC 27006 'Structure: MOBILE HOME Township: Oirections tt of Bedrooms: #ot People: Hwy 64 E,right on Hwy 801 ,then left on Baileys Chapel Rd. 'Water Supply: N/A Type of Business: Basement: �Yes❑No Total sq. Footage: No.Oi Employees: 'Proaosed Improvement: Remodeling Kitchen and Adding Carport 'Release Conditions `"' R�+ 7! 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? OYes �NO ApplicanULegal Reps.Signature: 'Date: � � 'Issued By: 2�40-Nations,Robert 'Date of Issue: 0 9 � 1 0 � a 0 1 4 Authorized State Agent: �— **Site PIan/Drawing attached.** OHand Drawing �Import Drawing �• • . a � I . , Da�ie County Health Departr�lent 4��is�� Environmental Healt�l Section � � A-�.� P.O.Box 848 ����M~ �A PAID • � ����� � �,�,�; 210 Hospital Street ��r��;, Q: '� �ate; ' ' Courier#:09-40-06 - �.� . ""��� r— . ' ,� � , R�ptve�tL�Y�.'__ Mocksville,NC 27028 Phone:(336)-753-6780 Fax:(336)-753-1680 ON-SITE WASTEWA' � � CATION (Check One) Replacement Remodelin Reconnection ,.l �,,�I �/(�. /��'.l Qp � Name: W' S Ur� '���L�� ""` w' � e Number 3 36'�7 0' '�r' �i S Z- (Home) Mailing Address: �{� S (�l (Work) � �w A1 G 2�0�� E�aa�ress: �'E'�. ►'GQ�arn��i�'C�I�''���. 0 • n � Gor» Detailed Directions To Site:� b��J '�'v �Gt,l��-NS �tiep�[ �d� _ '�' oti1 . ��(c�,5 ��. ��� G�-F�n R74' � cy s GP,�,�P r��. Property Address: q G 27vo� - - �g-aoo -�a -�� Please Fill In The Following Information About The EXIST7NG Facility: � f C � 'r/ Name System Installed Under: ��`� J� �W( Q,��Y�' Type Of Facility:�� I� /'N� �a7�'�� Date System Installed(Montl�/Date/Year): �_`a� Number Of Bedrooms: � Number Of People: L' Is The Facility Currently Vacant? Yes 1'�0� If Yes,For How Long? Any Known Problems? Yes ]Vo/ If Yes,Eaplain: a/ Please Fill In The Follow' Infortnation About e NEW Facitity. ��Q/yl��'I/� ��`1P�L,Q ��� ��j�� /2-f' ��_ Type Of Facility: �� ��/ 1 �l.eY�-� wnber Of Bedrooms: � Number of People �-- Pool Size: Garage Size: Other. Requested By: � Date Requested: � i e For Environmental Health Office Use Only Approved Disapproved Comments 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 (e�ctended or ' ' d)that the on-site wastewater system will function properly for any given period of time. Payment: Cas Ch Money Order # Arnount:$ , Date: Paid By: Received By: Account#:���� Imoice#: r _ , � _ . ._, ' � 1 _ .._ , __ . _ __ _ _ �� _ . � _. :. _ .._ � _ _._ . . _... _ . _ . . ______ � � . ..._; ;�._. _..•__. _ .._ .. _ __ .. �._ __ . • _ .. __._. . . .. . __... _ ...i . ....... .. __ _ .. t . ' - �. � . . ' . . 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DAVIE COUNTY HEALTH DEPARTMENT 3���� IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION •NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a Sanitary Sewage Systems , Permit Number Name���� c� U.� 1 � � � --- Dale J �� � �� N� I 9 � � J � � Location �� � � �'� �'�,��. ,�51.�� � �`)'C,,�� �'Z_ ,N �.. ��7 �o (. 1.. "� ,~__ � � s\\ �� '� `, 1.� �� ���`"—�1�.�r�/��:"'-,.���..\j,F� \� `\ � �` \� .`( \�J. ^.)1.-� ����\��.r . , ��� ��� , .t a���� �- � , Subdivision Name Lot No. Sec. or Block No. Lot Size �--_ House � Mobile Nome ____ Business _— Industry No. Bedrooms �->_ No. Baths _�=— No. in Family L� _ Public Assembly Other Garbage Disposal YES p NO [� Spe ifications for System: � � � - 1� o � Auro Dish Washer, YES d NO p �'' ,� Auto Wash Ma^hine YES p�' NO Q � � ��� �i � � ' � >>� v�� Type Water Supply �--- � �J r�� -------- �>`�- � a\�, � ��,e � - 'This permit Void if sewage system described below is not installed within 5 yLars from date of issue. This permit is subject to revocation if site plans or the intended use change ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT�LAYOUT BEFORE INSTALLING THIS � � . SYSTEM. � ,. C�. ,���_. � U V ... � , `� ,,� � � � � �� \'� , S i .--_-- -,. . ,- � : a�' L'..._.--_---'_--=;" ,� l c> c,��-_,-~"..— ._ __... ,_,_�____.._--,_ __._...._____ ..._- _.._-- 9 � , `, -.� � c���,____------- � Improvements permit by �`�---� ������� �•-��� ------ , •Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M., 1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion.Telephone Number: 704-634-5985. Final Installat�on Diagram: System Instatled by ��N�� � n���+ �Q�_ i' /�a � s� � �ud' �oa� /4�' Certificate oi Completion �� __ Date _L �� ` �� _ 'The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period oi time. . . �. ,, .I_ : � �� t�.. ��_ .; _ '� � . �- ;.) , c�'� �U � . ' i,.'�.w,i` _...: � f '� '"" DAVIE COUNTY HEALTH DEPARTMENT ���J . � � � ��� � IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION . � . _;�f-� '� -�-`-"� , , :NO�E:,Issued in Compliance With Article I I of G.S.Chapter 130a • � � � Sanitary Sewage Systems , ,_ Permit Number Name� ��'��,> � � \ �='���� �� --- Date � � -' � � N� I � 7 5 ,.. _ � � �. ._._. ' LoCation � � ~f 'C� .���.�. r� t i:. ;�,� t'\ ��1'i•.ti� � -._ ,``.J �. � �j c>t� C.� . — �— � — ; _ , _ , . , ' . —` ` ---G -2 ' r��Qd � ; Subdivision Name Lot No. °�Sec. or Block No. Lot Size ���___ House '� Mobile Home ____ Business __ industry No. Bedrooms -�_ No. Baths _ ��'-_— No. in Family ��t _. Public Assembly Other Garbage Disposal YES p NO Q� Specifications for System: ,. � . �,J � � Auto Dish Washer YES [� NO p � '"�� ,�. � Auto Wash Ma^hine YES �]�' NO [� • � �� ,�' �, � � i� � :�, � - X ) r� � �>;� _ iype Water Supply ,_._ '�• > 1 � --------- �-..,�:._- u� ��1 :�� \ ��� > ____- 'This permit Void if sewage system described below is not installed w�thin 5 y�ars from date of issue. This permit is subject to revoCatiUn if site plans or the intended use change ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT�LAYOUT BEFORE INSTALLING THIS SYSTEM. 1�'. �_ �--�.. 1 � �� � � U ll _ .', I `,_' r.' ��. . f i `.... . C.� ,. + � _.��,,,,; i ti. 1 `� � . .�:� � 11 �, , � . � _ a,. --.---1""__ - % , _._---' ,_.._ t> _--- _____._.-- , �\ � ___._____---.----___ � : _..._�_. _____ , __ � _---_ __._ , ___ __.. , , � � Im rovemenls permit b ��• �''�� P Y ----_— � 'Contact a representative oi the Davie Counry Health Department for finai inspection of this system between 8:30•9:30 A.M„ 1:00•1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634•5985. Final Installat�on Diagram: System Installed by � ���.y( w ���'� ��F�- � � y� u �� �' i�� ' ; �, f ' � ' C _. �' _ _ r' ���` OU' Certificate of Completion `-_ ����" Date - a� J b _ 'The signing oi this certiticate shall indicate that the system described above has been instailed in compliance with the standards set forth in the above regulation, but shail in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. , . . , � . . • d � o a 'T.,,� DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) NAME � P��� �I � `-� � 'P� �� PHONE NUMBER l � �' c�� � � ADDRESS_ _b� � d � �� SUBDIVISION NAME ��,v� ��c.-e � N .C� '�� d 0(o LOT # DIRECTIONS TO SITE __ b� C;�.�\��0 I ,N � �' G� �� CS� �a c>.� �4_� ����- - C� \� ��.. ��- DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY o v s� NUMBER BEDROOMS � NUMBER PEOPLE SERVED � TYPE WATER SUPPLY �� SPECIFY PROBLEM OCCURRING ���.�vsw� �'� `����. s� DATE REQUESTED � �� r `� � INFORMATION TAKEN BY � • This is to certify that the information provided is correct to the best of my knowledge,and that 1 understand I am responsible for all charges incurred}rom this appiication. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev.1/93