164 Boxwood Church Rd DAVIE COUNTY HEALTH DEPARTMENT
4 Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990003426 Tax PIN/EH#: 5755-20-2074
Billed To: Masuki Williamson Subdivision Info:
Reference Name: Location/Address: 164 Boxwood Church Road-27028
Pro osed Facility Residence Property Size: 3.15 acres
ATC Number: 3936
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST 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 WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD yO�F FIVE YEARS.
Environmental Health Specialist's Signature: C 1/&, Date: �0"
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 .S Chapter 130A,Section.1900"Sewage Treatment and
Disposal Systems,"but shall in NO WAY be tak as guarantee that the system will function satisfactorily for any
given period of time. D
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Septic System Installed By: v� � r- zv(✓
Environmental Health Specialist's Signature: y/ Date:
DCHD 05/99(Revised)
DAME COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990003426 Tax PIN/EH#: 5755-20-2074
Billed To: Masuki Williamson Subdivision Info:
Reference Name: Location/Address: 164 Boxwood Church Road-27028
Proposed Facility Residence Property Size: 3.15 acres
ATC Nurpber: 3936
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AUTHORIZATION 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 T /f #People #Bedrooms � #Baths_/
Dishwasher:, Garbage Disposal: ❑ Washing Machine;. Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial 13al Waste:
Lot Size Type Water Supply Design Wastewater Flow(GPD) ia
Site: New Ja Repair❑
System Specifications: Tank Size"GAL. Pump Tank GAL. Trench Width—ice– Rock Depth Linear Ft.��
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this
system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.****
Environmental Health Specialist's Signature: Date: D
DCHD 05/99(Revised)
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC
Davie County Health Department
Environmental Health Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. ` 'Refer to the INFORMATION BULLETIN for instruct�/Iilons.
1. Name to be Billed Y�1C�,sed K ��� '(� aC Contact Person �-21'v
/}�� 1 G
Mailing Address ,kct. ��(5v��1'/!Z^(pl `ii(�n1TVn1_ � Home Phone(,336�/
City/State/ZIP �hC���=mit��1� ?�' �7Q�tr� Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: ❑ Site EvaluationImprovement Permit/ATC E3Both
4. System to Services E3 House 13 Mobile Home 13 Business ❑ Industry ❑ Other
5. Type system requested: Conventional ❑ conventional modified ❑ innovative
6. If Residence: # People # Bedrooms # Bathrooms
❑Dishwasher ❑Garbage Disposal Mashing Machine ❑Basement/Plumbing ❑Basement/No Plumbing
7. If Business/Industry /Other: verify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
8. Type of water supply: County/City ❑ Well ❑ Community
9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes ❑No
If yes,what type?
***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST.BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions: WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Tax Office PIN: ` 5S- -a 0 D 36 t.✓ 00
Property Address: Road Name 1 /3Yoe
Citymp
If in a Subdivision provide information,as follows:
Name:
Section: Block: Lot: Date home corners flag ed: �
7
6L-
This is to certify that the information provided is correct to the best of my knowledge. I up
and that any permit(s)
issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or if the information
submitted in this application is falsified or changed. 1,also,understand that I am responsible for all charges incurred from
this application. I,hereby,give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property located in Davie County and owned by
to conduct all testing proc dures as necessary to determine the site suitabi y. Lik
DATE � SIGNATUR
E
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).
Site Revisit Charge
Datc(s):
Client Notification Date:
EHS:
Sign given Account No. ( l�
Revised DCHD(05103 Invoice No. 3
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VIE COUNTY HEALTH DEPARTMENT
2p04 Environmental Health Section
OAC PO Box 848/210 Hospital Street
Mocksville,NC 27028
0-
Phone: (336)751-8760
OA
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMENT❑ REMODELING ❑ RECONNECTION ❑
Name: Phone Number; ( ) d a 7o6 (Home)
Mailing Address: U tt 220) 0--& Q 6 SCO JF VAP S N (Work)
YY-�a n k V,`l I(s m 0 a�70a8'
(� mo
Detailed Directions To Site: GD pS
1 .S Ato 7Ay DI AN�,(,t'nod e h U1^6-b 1 A N �--t
4
Property Address:
Lol
/Please Fill In The Following Information About The Existing Dwelling.
✓ JL`a 8. 7:7- �-`"
Name System Installed Under: Type Of Dwelling:
Date System Installed(Month/Day/Year):_ Number Of Bedrooms: Number Of People:
Is The Dwelling Currently Vacant? Yes❑ No❑ If Yes,For How Long?
Any Known Problems?Yes❑ No❑ If Yes,Explain:
h Lid - 34
Please Fill In The Following Information About The New Dwelling:
Type Of Dwelling: umber Of Bedrooms: Number Of People:
e
Requested By: Date Requested:
(Signature)
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(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 #:
DAVIE COUNTY HEALTH'DEPARTMENT
a, Environmental Health Section
. PO Box 848/210 Hospital Street
Mocksville,NC 27028
Phone: (336)751-8760
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMENT❑ REMODELING ❑ RECONNECTI�yON/❑
Name: 1,1 Pt S 1 i ;t�vl\C r)' ( Phone Numbe �' � /06 (Home)
Mailing Address: L UY(.tl I-.C'G'. 7)zN5 (Work)
n
Detailed Directions To Site: Z>( l�rv• �f Pte! R!4 V)n �1ro�1 Wr�_�1 r h1
lf� �'$
Property Address:
tot\t1v
Please Fill in The Following Information About The Existing Dwelling.
41
Name System Installed Under: '• t- P (1 Type Of Dwelling:
Date System Installed(Month/Day/Year):_ /9 �}` Number Of Bedrooms: Number Of People:
Is;The Dwelling Currently Vacant? Yes❑ No Cl k.If Yes,For How.Long?.
Any Known Problems?Yes❑ No❑ If Yes;Explain ; f
Please Fill In The�;Followin Information About'The New Dwellin
Type Of Dwelling: umber Bedrooms: Number Of People:
Requested By: JL Date Requested:
(Signature) '"
For.Environmental Health Office Uge.Only ,
Approved ❑ Disapproved ❑ t;
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 h
guarantee(extended or limited)that the on-site wastewater system will function properly for any given period of time.
Payment: Cash❑ Check❑ Money Order-O"# Amount: $ Date:
Paid By: Receivea,�;y: ,
f
;Account #• (, L.... Invoice #:.
-�`� -
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C.RAY CATES certify that on OC'k 28 , 19 92 , I surveyed the property shown on this plat;
tfidt•the property lines and location of all structures are accurately shown hereon; that no structure locitVD10h1tt 4 property
1.4
encroaches on any adjacent street or property, and that no structure on adjacent property enejq"A, 4Qk,;'4jnIses
surveyed." JUNE 17,1994 (house location )
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PARCEL 41.03 0_ / b �da1'1.CI�_t PARCEL 47
JAMES W. PHELPS BILLIE• J. BECK'
D. B. 122-270 ' "3 D.B. 146-847
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l5I5.331 to rt.= N 15°-321-20j1 W Q. road
U.S.601 and
Boxwood Church Rd. U. S . HWY 601
PROPERTY OF
- MASUKI M . WILLIAMSON
LOT NO. 41.09 MAP OF DAVIE COUNTY TAX MAP N-6 BLOCK NO.
JERUSALEM TOWNSHIP
DEED BOOK 166 PAGE 152 DAVIE COUNTY, N. C.
SCALE: i INCH= 100 FEET
.foe No 1121-F
SOYTNt•N PHOTO MINT • SUPPLY CO.—ININSTON.IIAL[N N50999
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