130 Beaver Branch Trail HEALTH DEPARTMENT RELEASE For Office Use Only
*CDP File Number 157339- 1
Davie County Health Department
�er�fo
210 Hospital Street County ID Number.
P.O. Box 848
Evaluated For. HDR/WWC
Mocksville NC 27028
Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID 0 8 / 1 9 / 2 0 1 9
UNTIL
Applicant: Larry Tutterow Property Owner. Larry Tutterow
Address: 130 Beaver Branch Trait Address: 130 Beaver Branch Trail
City: Mocksville City: Mocksville
State2ip: NC 27028 State2ip: NC 27028
Phone#: (336)602-3813 Phone#: (336)602-3813
Property Location 8 Site Information
Address 130 Beaver Branch Trail Subdivision: Phase: Lot
Road# Mocksville NC 27028
SINGLE FAMILY Township:
'Structure: Directions
#of Bedrooms: 3 #of People: Hwy 64 West past last Lake Myers tum Right on Callahan,2miles on
right Beaver Branch Trail
'Water Supply: PUBLIC
Type of Business:
Basement: [—IYes�No
Total sq.Footage: No.Of Employees:
'Proposed Improvement:
Pole Bam/Enclose maybe in the future
'Release Conditions
eu
Follow attached drawing 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 ONO
Applicant/Legal Reps.Signature: *Date: /
*Issued By: 2140-Nations,Robert *Date of Issue: 0 8 / 1 9 / 2 0 1 4
Authorized State Agent:
**Site Plan/Drawing attached.**
O Hand Drawing Olmpoft Drawing
Davie County Health Department
0 � Environmental Health Section
P.O..Box 848 �
", 210 Hspital Street
. p Courier# : 09-40-06 4;
U Mocksville, NC 27028
Phone:(336)-753-6780 Fax:(336)-753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Name: 4—rU40,rn Phone Number 3 V (Home),
Mailing Address: � U Flo (Work)
Z,o Email Address:
Detailed Directions To Site:
Property Address: /
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: Z � Type Of Facility: 74
U56 l0 .6 7,46,
Date System Installed(Month/Date/Year): { `� Number Of Bedrooms: Number Of People:
Is The Facility Currently Vacant? Yes ) If Yes,For How Long?
Any Known Problems? Yes If Yeses,Explain:
Please Fill In The Followin formation About The NEW Facility:
Type Of Facility: ' Number Of Bedrooms: Number of People
Pool Size: Garage Size: Other:
�►. Requested B Date Requested:
( i e)
For Environmental Health Office Use Only
�rye Disapproved
Comments:
10V' Ay 1-7
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.
Payment: Cash - Check Money Order # Amount: Date:
Paid By: Received By:
Account#: 1!5 1-3 1 Invoice#:
,
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76
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Pe n t �( ' D VYE CpUNTY HEALTH DEPARTMENT7
✓' �"'� � " Environmental Health Sectwn PROPERTY INFORMATION
✓' , P.O.Box 848
Directions to propert): Mocksville..NC 27028 Subdivision Name:
Phone#:336-751-8760 Section: Lot:
AUTHORIZATION FOR
Ui`� JL ,1C hI WASTEWATER Tax Office PIN:#�
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 2069 A Road Name:
**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 plying for Building Permits
(In compliance -ittt�ARtc 'III f G. . apte OA, tewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
/ rr—• ff� ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIR �THSP CI ST DATE SS ED
RESIDENTIAL SPECIFICATION:BUILDING TYPE Off( #BEDROOMS 3 #BATHS 2 #OCCUPANTS_ GARBAGE DISPOSAL:Yes or .
COMMERCIAL SPECIFICATION:FACILITY TYPE #PEOPLE #PEOPLEISHIFT - #SEATS INDUSTRIAL WASTE:Yes or No
ID's�G�•S nn,,ll'' yy��FS -
LOT.SIZE TYPE WATER SUPPLY �-"� �DIGN WASTEWATER FLOW(GPD) ��"�NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS:TANK SIZE GAL PUMP TANK GAL TRENCH WIDTH ROCK DEPTH LINEAR FT.
OTHER 1 s-r rJV t 10 1 yC. �Iek,Zh-T I u, J4L-vI'
nn(
REQUIRED SITE MODIFICATIONSICONDIfIONS:'14STALI D►J Cv-TOOL,It�"S7�L�'. t-wc--s VI D. M I J.
IMPROVEMENT PERMIT LAYOUT
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r wf e 1.-a. C-t-Te--� '1
1�QC1� [�tT�'YJATJt., ✓4l J
**CONTACT A REPRESENTATIVE OF TH DAVIE COUNTY HEALTH DEPARTMENT FOR AL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9:30 A.M.OR 1: -1:30 P.M.ON THE DAY OF INSTALLATION. HONE#IS(336)751-8760.
OPERATION PERMIT
Cn�h �) A
fRM INSTALLED BY:
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AUTHORIZATION NO.&I��/4 OPERATION PERMIT BY: DATE: (�
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSESCRIB A VE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOS STEMS",BUT SHALL IN NOWAY BETAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
nctmoza¢(mal
Pernutt 's (� f D. VIE COUNTY HEALTH DEPARTMENT '�'� s v
Name: ���� ' '�� � u Environmental Health Section PROPERTY INFORMATION
1.—i. P.O. Box 848;
Directions to Property: t" Mocksville,NC 27028 Subdivision Name:
bti�Int.� Phone#:336-751-8760
Section: Lot:
AUTHORIZATION FOR
UP-1 aaL WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION
iS6 r} +
AUTHORIZATION NO: 206 A . Road Name:r,;m16;k
**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 compliance wilh-Mic '11 of G. . hapte OA,W tewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIR�S liVT "IiEA�TH SPECI ST DATE SSPED
RESIDENTIAL SPECIFICATION:BUILDING TYPE jL #BEDROOMS #BATHS a- #OCCUPANTS GARBAGE'DISPOSAL:Yes or Jo
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
P4- � 5
LOT SIZE TYPE WATER SUPPLY CU)N)T�Dy�
ESIGN WASTEWATER FLOW(GPD) 3(0 NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE - GAL. PUMP TANK GAL. TRENCH WIDTH ROCK ROCK DEPTH I LINEAR FT. �
OTHER ' U- -1S11..970T1 -Tc�rJL+T
�
REQUIRED SITE MODIFICATIONS/CONDITIONS: k%.STAt...I- pt,1 . C.t TOJD�, ( {��,L�: 1. 1aLS .Q. M I Aj.
IMPROVEMENT PERMIT LAYOUT
�a171 �C�JCi•X��S'' 1 L>C> V-
Cv, dtr'Ctc`�?�ATzb J�SAI.�
**CONTACT A REPRESENTATIVE OF TLDAVIE COUNTY HEALTH DEPARTMENT FOR INAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9:30 A.M.OR 1: .M.ON THE DAY OF INSTALLATION. EPHONE#IS (336)751-8760.
OPERATION PERMITT TA �
S INSTA ,
LLED BY:
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VAL ve to ar J%Z;�
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TO �aWlt-
AUTHORIZATION NO�4 OPERATIOR PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTE ESCRIBfe A VE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 1 I OF G.S.CHAPTER 130A ,SECTION.1900"SEWAGE TREATMENT AND DISPOS STEMS",BUT SHALL IN NOWAY BETAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 01/02(Revised)
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DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130-Article 13C)
OWNER OR CONTRACTOR :'' i•n'. DATE - PERMIT
LOCATION •, •..�. r� ��-:` 7 -5'•
N° 1218.
• r
for ;� f. f.p. S.R. N0. ; �'
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE CI MOBILE HOME C3 BUSINESS ❑
House Trailer 800 Gal. 400 Sq. Ft.
NO. BEDROOMS NO. BATHROOMS Two Bedroom House -800-Gal N e600 -Sq. F.L.
GARBAGE QISPOSAL UNIT YES ❑ . NO Three Bedroom House '.900 -Gal.: '•1900,-Sq.-.Ft.,
AUTO. DISHWASHER YES ❑ NO ❑ Four Bedroom House 1000 Gal. 1200 Sq. Ft.
AUTO. WASH. MACHINE YES ❑ NO ❑ r
SITE SUITABLE YES ❑ NO ❑
SIZE OF TANK gal.
NITRIFICATION FIELD sq. ft. !•'`` ,
DEPTH OF STONE IN LINES: ,,� {� �,J �� '•� ;
WATER SUPPLY: Individual./,113 Aublic ❑
IMPROVEMENTS PERMIT BY :�'" � ''�"=-' INSTALLED BY
CERTIFICATE OF COMPLETION By . Date �0
(8/16/73) *Construction must compl with all other applicable State and local re ulations
LOT AREA
.�. .r- 10 0' wcrd
oa o Q M 9 A-)'-F
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vo 3 - 98o 9G�,
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DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
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APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) d
L
NAME �uL� T� ► 1�'�� PHONE NUMBER / ( 7"-7'423 �.
ADDRESS 13L w04VO4L �� SUBDIVISION NAME o
LOT #
DIRECTIONS TO SITEf5 6dlyukv �C
DATE SYSTEM INS ALLED / 77 NAME SYSTEM INSTALLED UNDER `^'`
TYPE FACILITY �: NUMBER BEDROOMS /2--NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING Sok�AcG O
DATE REQUESTED DZ INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowiedge,and that I understand I am res for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93