The URL can be used to link to this page

204 Blue Bird Ln DAVIE COUNTY HEALTH DEPARTMENT . •:• • Environmental Health Section �G� ( Z—� `" °� P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (33G)75]-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002041 Tax PIN/EH#: 5861-30-5626 Billed To: Kendall Howard Subdivision Info: Reference Name: Location/Address: Blue Bird Lane-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3002 **NOTE**This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHOWZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type � #People � #Bedrooms � #Baths� Dishwasher:� Garbage Disposal: 0 Washing Machine;� Basement w/Plumbing�BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow(GPD)C�� Site: Nevy��Repair❑ S stem S ecifications: Tank Size � y p �GAL. Pump Tank GAL. Trench Widths,� Rock Depth� Linear Ft�� Other: Required Site Modifications/Conditions: i1�1PROVEMENT/OPERATION PERMI UT- VED EFFLUENT FILTER. RISER(S) IF C,"BELOW FINISHED CRADE. ****NOTICE: Contact a represen ' oft vie County Health Deparhnent for final inspection ofthis system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m. on 'nstallation. Telephone#is(33()751-87G0.**** �� b�� o �- - -� ,, . N �� /�_�� ` l r�`� �� Sc �'� ; �o�ot��b�� l�,�X��,/.2 �� `� � ' ��✓� e�` b� - - � - '- � 7U � 2 ;� �,,� �. �6 � �wl � �� yw � Environmental Health Specialist's Signature: Date: �/�� DCHD OS/99(Revised) . . , �� ' �,' � ^ �� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (33G)751-8760 Account #: 990002041 Tax PIN/EH#: 5861-30-5626 Billed To: Kend�ll Howard Subdivision Info: Reference Name: Location/Address: Blue Bird Lane-27028 ro osed Facilit : Residence Pro ert Size: see ma ATC Number: 3002 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MiJST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems, Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWA NSTRUCTION IS V I FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �-- Date: !!_�` U/ CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit 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. `--' h j'3�7 �l b� 31�� - �'r�S� �tc� �'�► 5;�� r`' Septic System Installed By: Environmental Health SpecialisYs Signature:___(! �i'�%�f" Date: �/— 'Y�'��,, DCHD OS/99(Revised) � � � , � .?- ,:;: ,, � APPLICATION FOR SITE EVALUATION/Ilb1PROVEMENT PERMIT&kTC Davie County Health Department t� Environmenta/Hea/th Section D 1-5 ��C�r� P.O. Box 848/210 Hospital Street Mocksville, NC 27028 NQV 6 ,. ,, � (336)751-8760 - �`�'`''� E � ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE UTA�D%��.��ACTH INFORI�TION IS PROVIDED. Refer to the INFORMATION BULLETIN for �tions�:�'��rY ! 1. Name to be Billed ��^ n(�l l ("��'1C►v(� Contact Person /7Pyt(�X `�i,J['v'W� Mailinq Address �� L->1en r� ��1e V1 KC.� Home Phone ��' �� -� c�ty/state/z=p 1�1ockScli��e �C 2'�oZ`6 sus�ness Phone ��n- 7!�(�-y//1/ 2. Name on Permit/ATC if Different than Above Mailinq Address City/State/Zip 3, Application For: ❑ Site Evaluation � Improvement Perm3.t/ATC ❑ Both a. system to service: ❑ House 0 Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People � # Bedrooms �� # Bathrooms � Fd"Dish�rasher ❑ Garbaqe Disposal �Washing Machine [=t�Basement/Plumbing �I Basement/No Plumbing 6. If Susiness/Industiy/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City ❑ Well ❑ Community s. Do you anticipatc additions or expansions of the facility this system is intended to scrvc? ❑ Ycs 'f�'1�10 If yes,what type? ***IMPORTANT*'�*CLIENTS MUST COMPLETETNE REQUIRED PROPERTY 1NFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMIT7'ED by the client with THIS APPLICATION. � Property Dimensions: �O(o.i�+l X �j�2,1�x 32`��85x7$(o�� WRITE DIRGCT'IONS(from IVlocksville)to PROPGRTY: Tax Office PIN: # �1��?I.�.Sfo2� l�Wl1 �5�� -�b l�oc,�r'i��d�✓n �i�� Property Address: Road Name !J)ue �'�i�'� 1-+v �"4�..f � �'1 � ,l�i� G/L � r(�o,2t;�� CitylZip �V1c�c:ksvi�� ' z�UZ$ ��'1 li� C�✓) U�� b�� 't � llCrvss _ If in a Subdivision provide information,as follows: kr�,,.. ��il d�ut �,�rd �n � �es��l� eF 21b Name: ��u� b�r� Lr�• Section: Block: Lot: Datc Property rlagged: �� O "�� This is to certify that the information provided is correct to the best of my knowledgc. I understand that any permit(s) issued hereafter are subject to suspension or revocation,if the site plans or intended usc change,or if the information submitted in this application is falsified or changed. I, also,understand tl:ut I an:responsible jor u1l cltarges i»curred fronr lhis applicatio�r. I,hereby,give consent to the Authorized Representative of the Davie County Healtl� Department to enter upon above described property located in Davie County and owned Uy �'b'�Cc✓ti � D �s✓ to conduct all testing procedures as necessary to determine thc sitc suitability. DATE ��n" C� I SIGNATURE� „�F�f �. ��°i ,D� THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Sitc Revisit Cl�argc Date(s): Client Notification Date: �HS: Account No. � 1 Revised DCHD(07/99) Invoice No. �-- � y" . . _ .-, :- � ` . • n�I 5� 1 - � �,- P �� —,..: M � � � � . � �. . 10 2 � ��, �� 1�� 3.51A N U � 5626 u u _ „ ; 6.12A -3867305626 �579 �. � �' � a95. '�� • Parcel ID:F70000000305 Account Number.�000002498000 • PIN:5861305626 Lega11:3.51 AC E OFF R 1635 • Owner Name:ARMSWORTHY MARY E Owner/Address 9:ARMSWORTHY MARY E • OwneN,4ddress 3:129 SQUIRREL LANE • City,State Zip:ADVANCE,NC 27006-0000 Land Value:$35,920.00 • Building Value:$0.00 Out Building/Extra Features Value:$0.00 • Assessed Value:$35,920.00 Assessed Acres:3.51 • Deed Book/Page:00167/0310 Deed Date:1993/02/25 ' • Sales Price:$0.00 Property Address: F70000000305 • County Zoning:R-A Census Code: • Fire District: Flood Zone:ZONE X • Flood Community: Flood Panel: • Flood Map Date: Soil: • Township:FARMINGTON Voting Precinct:SMITH GROVE �G DAVIE COUNTY HEALTH DEPARTAAAENT ,- � � : �� IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ..� *NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a Sanitary Sewage Systems ��t� � Permit Number Name f� .� �.�r��/o�?��✓ /,-��:►'.vGG Date �-�� –.� NO Location ��' •-a,- �.�,�:�r1 " ��d��a� ` ,� %Z`"7.� °� � v ,�-' J � ��'�i��t� oz� �d �� __ ; Subdivision Name Lot No. Sec. or Block No. Lot Size �-�i9� House Mobile Home `� Business _— Speculation No. Bedrooms �_.No. Baths � No. in Family�__ Garbage Disposal YES ❑ NO J� Specifications for System: Auto Dish Washer YES � NO ❑ ��)�„��y� �,,�'',x Auto Wash Ma:hine YES NO ❑ � Type Water Supply _ �-G�,� __ `��'�S ��'a ` 'This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change. . - - _ . r . , ` ��l� , � �f�f � , , �� ' � .� � _ � � . /v .� � Im rovements ermit b .,!��'�— P P Y '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 day of completion. Telephone NumbPr 704-634-5985. Final Installation Diagram: System Installed by � Certificate of Completion Date 'The signing of this certificate shall indicate that th�' 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 of time.