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648 Deadmon Rd DAVIE COUNTY HEALTH DEPARTMENT '�oP Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990002072 Tax PIN/EH M 5747-72-5649.jw Billed To: Johna Wiseman Subdivision Info: Reference Name: Location/Address: 648 Dedmon Road-27028 Proposed Facility: Residence Property Size: 0.800 acres ATC Number. 3021 **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 1 l 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-IleGarbage 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/&P GAL. Pump Tank GAL. Trench Widt Rock Depth 16L Linear Ft��d` Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISERS)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.**** d D� ppj,15ju Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) • DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section P.O.Bog 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990002072 Tax PIN/EH#: 5747-72-5649.jw Billed To: Johna Wiseman Subdivision Info: Reference Name: Location/Address: 648 Dedmon Road-27028 Proposed Faciflty: Residence Prol2erty Siacres ATC Number: 3021 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 WASTEWACON TRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: 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 TF Disposal Systems,"but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. s-a Q� �d Septic System Installed By: Environmental Health Specialist's Signature:. Date: /^ //—e DCHD 05/99(Revised) y \� Q��AP TION FOR SITE EVALUATION/IMPROVEMENT I'EIi11�IT&Ai .�,. er" /Qo� Davie County Health Department (��t5 Envirwnmenta/Hea/th Section e DEC 5 2001 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 ENVIRONMENTAL HEALTH (336)751-8760 DAVIE COUNTY ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed , �Dl�lQ �15e'y&a i l Contact Person &A nn /� /,, // Mailing Address (T CI�.,� Home Phone /7d I -la15 /—�Q/f7 City/State/ZIPAlq( Business Phone 'l 0 "(03 L'/57 y0 2. Name on Permit/ATC if Differen an Above Mailing Address City/State/zip 3. Application For: ❑ Som�ite Evaluation Improvement Permit/ATC Il Both I o 4. System to service: 131 use ❑ Mobile Home X❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms # Bathrooms leDishwasher LI Garbage Disposal L Washing Machine 11 Basement/Plumbing 1.1 Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes is # Showers _ # Urinals # Water Coolers IF FOODSERVICE: # Spats Estimated Water Usage (gallons per day) 7. Type of water supply: t-County/City ❑ Well U Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes Ir No— If yes,what type? ***IAIPORTANT***CLIENTS AIUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUES'T'ED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Q ? Property Dimensions: © v A uS WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: # l "( ` I '�� I l�al '✓ , �� L�jD-`(Xi✓IlA� �-t f� Property Address: Road Name QAC, (f-7NC City/Zip—4 11V- If in a Subdivision provide information,as follows: Name: Section: Block: Lot: Date Property Flagged: This is to certify that the information provided is correct to the best of my knowledge. I understand 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. I,also,understand that I am responsible for all charges incurred frown this application. I,hereby,give consent to the Authorized Representative of the D•v1c County He:Ith Department to enter upon above described property located in Davie County and owned byg` to conduct all testing procedures as necessary to determine the site suitability. DATE D SIGNATURE �. 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 ' Date(s): Client Notification Date: a r/ EHS: Account No. Revised DCHD(07/99) Invoice No. /t_ t -'-� DAVIE COUNTY HEALTH DEPARTMENT • - 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 ❑ Name: :.y"', �.l �� s'' %f �, :? (_r ? Phone Number: `�D 4- /? 'i�N me) �, Mailing'Address: -4!(L-) %`���.'1''l.�,c? J/cA 'li4- �i t,t!~ !• (Work) Detailed Directions To Site: r0 11\6 t 1 )�(.t: �_,', : . ,,:_1./. -�,�.} ��1��..'i+ �- - /\�, .! �V� .�•� 1 )n� 4.; -1 );! `^��` l r+ .' l /1'� i f r ✓Y 1s f�': i 1 •. �,. `! j l tl.^� 'Y Property Address: Please Fill In The Following Information About The Existing Dwelling. Name System Installed Under: j': r, -, :F'! .? //;2'41 Type Of Dwelling: J c.c•'' L Date System Installed(Month/Day/Year): Number Of Bedrooms: >JNumber Of People: Is The Dwelling Currently Vacant? Yes EJB No❑ If Yes,For How Long? �I�/��'�-•j' �`. ��{L?:t , Any Known Problems?Yes❑ No 9- If Yes,Explain: Please Fill In The Following Information About The New Dwelling: Type Of Dwelling: .�!•'� ►-. - Number Of Bedrooms: "rNumber Of People: '- Requested By: /'f"I Date Requested: (Signature) For Environmental Health Office Use Only t Approved.-O' Disapproved ❑ J f Comments: -�' r'rl ✓- :`J ^"�✓�:/ t` fes'( iii✓.'.� J' J;� // `iii(.jf, /• .� air' ''a � �' ../i' ''� �l►'/�� J///T.j •�.-i/Jr( ()Jj f::i' J^',c_ .'' yip..,!• /:' 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❑ # J 'i Amount: $ —Date:- Paid ate:Paid By: - ,._ - Received By: Account #:- Invoice #: s i r i A'J o SITE \ \ f�Oil S 10'00'00' E 34.47 (l 2 j5, ' N 19'56'21' 30.1c, %4�;w \ \ 0 �01 VICINITY MAP - Ro ti kO,y AREA= 0.80_0 __AC. /u�6 SEi -40 - LOT #4 AL h ,�;,•, \'�� � ��' L-2527 ROOSTER'S RUN / / < 4 may' :� o.S3a P.B. 7, PG. 32 / / :�9��osuR,4Q9. d: 20• y / `/ "Ifill C. TU O, / �1i71l11'I . 'Foz, LOT #3 �p Z o // ROOSTER'S RUN ./ 1, GRADY L. TUTTEROW. CERTIFY THAT UNDE b ch P.B. 7, PG. 32 / MY DIRECTION AND SUPERVISION, THIS MAP tJ ri / WAS DRAWN FROM AN ACTUAL FIELD SURVEY MADE BY TUTT( POW `URVEYING COMPANY. O W-z Z N 'O "d 60.00 03' Irl l W 1 ` / PPOFESSI❑NAL LAND SURVEY❑R. L-252 E�` Qr CO AI�t-Y 1 � / J 127 LIBERTY CHURCH ROAD 1 LOT ##5 t 10( f' v I LLE, N. C. C' 7028 1 ( 704) 492-5616 1 ROOSTER'S RUN ,A 1 P.B. 7, PG. 32 1 PLAT OF SURVEY FOR, HENRY' GRANT, 1 1 REVISIONS 1" = 80' APPROVED BY, DRAWN BY- JC' scALE L.TUTTEP0W 1 AUG-15-2001 FILE W`a1E� 17 DATE. _