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150 Call Rd+ DAVIE COUNTY HEALTH DEPARTMENT ,� Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-87C►0 Account #: 990002886 Billed To: Frank Carter Reference Name: Proposed Facility Bathroom IMPROVEMENT/OPERATION PERMIT �� 2� - � � Tax PIN/EH #: 5758-31-1925 B Subdivision Info: Location/Address: Call Road-27028 Property Size: see map ATC Number: 3786 **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 #People � #Bedrooms � / T #Baths � Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: � Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow (GPD) �"�� Site: New� Repair ❑ �/ System Specifications: Tank Size b�J GAL. Pump Tank GAL. Trench Width Rock Depth .�•2 Linear Ft.-� � Other: Required Site Modifications/Conditions: IN[PROVEMENT/OPERATION PERMiT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6" BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department 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 the day of installation. Telephone # is (33()751-87G0.**** �r' �jd-lf�� pll / � �� n� � � / Environmental Health Srecialist's Signature: Date: � �j l �'� � DCHD OS/99 (Revised) Account #: 990002886 Billed To: Frank Carter Reference Name: Proposed Facility Bathroom ATC Number: 3786 m DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (33G)751-87C,0 Tax PIN/EH #: 5758-31-1925 B Subdivision Info: Location/Address: Call Road-27028 Property Size: see map 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 OF FIVE YEARS. Environmental Health Specialist's Signature: / Date: _��L�J `/ CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on ImprovemendOperation 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. Septic System Installed By: Environmental Health Specialist's Signature : DCHD OS/9�Revised) Date: �p � � `��% `"� ��s. . `, (�n �� v ''� Q�� '� � zoo4 � 1', i�a� 2 �y PLICAZION FOfi SITE EVALUATION/Ih1F'fi0VEh1ENT PERhfI'i & A7C : Davie County Heafth Department Environmenta/Hea/fh Section P.O. Box 848/210 Hospital Street ' Mocksville, NC 27028 ` (336)751-8760 * �4C *** APPLICATION CANNOT BE PROCESS�D UNLESS ALL THE REQUIRED Y�� PROVIDED. Refer to the INFORMATION BULLETIN ior instructions. 1. Name to be Billed�i�''� ��_�� Contact Person �a-�i� �(�j��ji�___ Mailing Address�, �� .�(_)jL �� Home Phone(�� '753 -��ry'7 City/State/ZIP ��<SV � I ��_ (V � Q(" /Q�� Business Phone (�JCG ) a / O `� �_r,�� 2. Name on Pexinit/ATC if Different than Above Mailing Address 3. Application For: ❑ Site Evaluation City/State/Zip .�Improvement Permit/ATC ❑ Both 4. system to service: ❑ House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: ❑ Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People # i�edrooms #� Bathrooms �_ ❑Dishwa3her ❑Garbage Disposal ❑Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. IL Business/Induatry /Other: veri£y type # Commodes $ Showers IF FOODSERVICE: # Seats 8. Type of water supply: ❑ C011nty�City # Urinals # Peopla # Sinks # Water Coolers Estimated Water Usage (qaiions per day) _ fd Well ❑ Community 9. Do You anticipate additions or expansions of tlie facility tliis systen� is iiitencled to sei•ve? � 1'es ❑ No If��cs, �vl�at tyPc? d_X.,��'ll`�� (.��f �9 U� _ ***IMPORTANT'°** CLIGNTS MUST COMPLBTETHG REQUIXED PROPER'I'Y INTORMA'CION RCQUGS"('Isll [3GLO�V. Githcr a PLAT or SITG PLAN MUST BESUBM/TTED by thc clici�t tivitl� TIiIS APPL[CATION. I'roperty Dimcnsions: 1'aa Officc PIN: �� Pc•opert}� Address: Road Name City/Zip If in a Subdivision providc informatiou, as follows: Namc: 1VRITC DIRGCTIONS (from A1ocl:sviilc) to PROPI:R'I'1': Section: Block: Lot: llate horae corners flagged: Tliis is to certify� ttiat the information pro��ided is correct to tIie best of my lcno�vledge. I understand tliat any permit(s) issucd I�ercafter are suUject to susi�eusion or revocation, if tl�e site plans or intended use cliauge, or if tlie information suUmitted in tt�is application is falsitied or clianged. I, also, ![111IC1'SIRIIlI II1QI I[IJII !'CSf70/1S1GIL' fa• a!! clrnrges iircrrrrec! fi•onr dris npplication. I,7�ereby, give consent to the Autliorized Repi•esentative of tl�e Davie Count�� IIealtli Departme�it to enter «pon abo��e described property locatcd in Davie County and owncd by to cunduct :ill tesling p►•ocedures as tiecessary to detel•[ni►ie tlie site suitabilit}�. DA'I'� �� L� SIGNATUI2E � �t ' TIIIS AIt�A MAY B� US�D FOR DRAWING YOUR SITE PLAN (I�icludc all of tlie follo�v' g: ESISt1I1� 111(I j)I'OpOSC(I pt•opel•ty lines and dimensions, structures, setbacks, and septic locations). �� v � , , s��►� �� `� I2criscd DCI�ll (OS/03 ; r' � �- � �, . -�- C �c � � Sitc Revisit Cliargc � n�t�(S,: Clicnt Notification Datc: EHS: Account No. �� I�ivoicc No. �—v � 1'f DAVIE COUNTY HEALTH DEPARTMENT �� • Environmental Health Section � " P. O. Boz 848/210 Hospital Street C�-' p� / J Mocksville, NC 27028 � G � (336)7S]-87(0 � Account #: 990002886 Billed To: Frank Carter Reference Name: Proposed Facility: Residence IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5758-31-1925 " Subdivision Info: Location/Address: Call Road-27028 � Property Size: 56.896 acres ATC Number: 3559 **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 �" #People � #Bedrooms � #Bath�s� Dishwasher: � Garbage Disposal: ❑ Washing Machine�l Basement w/Plumbing: � Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ � 'I Lot Size Type Water Supply _��/Design Wastewater Flow (GPD) t.5 �U: Site: New-O�Repair ❑ System Specifications: Tank Size •�/��AL. Pump Tank Other: Required Site Modifications/Conditions: / ' << / GAL. Trench Width cs ` Rock Depth � Linear Ft� 11�9PROVEI�'IENT/OPERATION PERM IT LAYOUT - APPRO�'ED EFFLUENT FILTER. RISER(S) IF G" BELOW F'INISHED GRADF.. ****NOTICE: Contact a representative offhe Davie CountyHealth Department 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 the day of installation. Telephone # is (33C)7i1-8760.**** -_...,._... -��2�n d � � . (/ � � Env�ronmental Health Specialist s Signature: �// DCHD OS/99 (Revised) Date: Y �� v