188 Evergreen LnDAVIE COUNTY HEALTH DEPARTMENT �d ! t —OD
y Environmental Health Section
P. O. Boa 848/210 Hospital Streets �D
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001262 Tax PIN/EH #: 5880-68-7966
Billed To: Lucy Myers Subdivision Info:
Reference Name: Lucy Myers Location/Address: Evergreen Lane -27006
Proposed Facility: Residence Property Size: 5 Acres
**NO�E '�"1 hIsblmprovement/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 Aasr #People -�� #Bedrooms #Baths --192
Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type
U
#People #People/Shift
Industrial Waste: 13'7
Lot Size Type Water Sgpply
Design Wastewater Flow (GPD)
/#SSeats
V101
Site: New Repair ❑
System Specifications: Tank Size AL. Pump Tank
Other:
Required Site Modifications/Conditions:
GAL. Trench Width Rock Depta—V Linear RAO
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.****
P
Environmental Health Specialist's Signature: &M-tTe. 14 Date:
�__ DCHD 05/99 (Revised)
W/.J�q -da
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990001262 Tax PIN/EH #: 5880-68-7966
Billed To: Lucy Myers Subdivision Info:
Reference Name: Lucy Myers Location/Address: Evergreen Lane -27006
Proposed Facility: Residence Property Size: 5 Acres
ATC Number: 2471
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: O - dC-2
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.
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
Date:
D1�05 R SITE EVALUATION/IMPROVEMENT PERMIT & ATC
avie County Health Department
ttttt��1�
_ Envifvnmenfa/HeaftSL-cGion
M 2 9 LuJ . Boa 848/210 Hospital Street
LV Mocksville, NC 27028
(336) 751-8760
Pei ffAl
e. Do you anticipate additions or expansions of the facility this system is intended to serve? TC�jYes ❑ No
If yes, what type? 2==
***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: S� WIRITE DIRECTIONS (from Mocksville) to PROPERTY:
11L Tax Office PIN: # ✓ 'q'o j 8 — S/o l
Property Address: Road Name .,' ---v ea !�Z- 2<- f'.v ,4 ue u u de. •- T ,0.x5 �al��
city/zip A✓�,vc .r/C :? 7006 Lvc a- aa w r+. -gee
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 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 procedures as necessary to determine the site suitability.
DATEE_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:
EHS•
Revised DCHD (07/99)
Account No. --7
InvoiceNo.
0
***!PORTANT***
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS
PROVIDED. Refer to the INFORMATION BULLETIN fore instructions..
1.
Name to be Billed
L ti C le /i , / J/►�� YE - s
Contact Person 4 Ly I K /" /5/5
00
Mailing Address�O.B.,
Home Phone
City/state/ZIP
<1fyo4 drya c _ ey _
Business Phone
2.
Name on Permit/ATC
if Different than Above
Mailing Address
City/State/Zip
3.
Application For:
❑ Site Evaluation
Z Improvement Permit/ATC ❑ Both
4.
system to Service:
House ❑ Mobile Home
❑ Business ❑ Industry ❑ Other
5.
If Residence:
# People #
Bedrooms � # Bathrooms .3
❑ Dishwasher ❑
Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6.
If Business/Industry/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
e. Do you anticipate additions or expansions of the facility this system is intended to serve? TC�jYes ❑ No
If yes, what type? 2==
***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: S� WIRITE DIRECTIONS (from Mocksville) to PROPERTY:
11L Tax Office PIN: # ✓ 'q'o j 8 — S/o l
Property Address: Road Name .,' ---v ea !�Z- 2<- f'.v ,4 ue u u de. •- T ,0.x5 �al��
city/zip A✓�,vc .r/C :? 7006 Lvc a- aa w r+. -gee
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 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 procedures as necessary to determine the site suitability.
DATEE_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:
EHS•
Revised DCHD (07/99)
Account No. --7
InvoiceNo.
0
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
anitary Sewage Systems Permit Number
Name "6/ z ��-S"a �f✓C,�}�.lr-r te- Date N2 6052
Location � e:A �J, — ����_� '
Aed
Subdivision Name
Lot No.
Sec. or Block No.
Lot SizeHouse Mobile Home __ Business _— Speculation
No. Bedrooms —No. Baths— No. in Family_
Garbage Disposal YES ❑ NO p- Specifications for System:
Auto Dish Washer YES W NO E]
Auto Wash Machine YES NO ❑ /�
Type Water Supply — 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.
Improvements permit by ---,& ZZ
*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 Number: 704-634-5985.
Final Installation Diagram: System Installed by
Certificate of Completion
44, eX - A % J MA_
14,.7 f 4c ev,^ .-7 bait
cv �s v4- e - Aa-
,
Date
"The signing of this certificate shall indicate that the 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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT.,
Davie County Health Department L _j 3 '
` Environmental Health Section
P. 0. Box 665
Mockaville, NC 27028
1. Application/Permit Requested By ( A LI///)/ I S
Mailing Address yj'57.' AV 1t"-- .s /V. 6 2 71 3
6. If house, mobile home: Subdivision Sec. Lot#�
No. of People Dwelling Dimensions VX -5'-0 C�•�� �yX� `f
No. of Bedrooms ,2 asement/Plumbing
,No. of Bathrooms_ ` Basement/No Plumbing
(\ Washing Machine Dishwasher 0 Garbage D:ispusat
7. If business, industry, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers
8. Type of water supply: V Public XPrivate Community
9. Property Dimensions
10. Sewage Disposal Contractor "-
11. Do you anticipate additions/expansions of the facility this system is
intended to serve? fr. Yes XNo
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of 5
years from date issued. Improvements Permits are subject
to revocation, if site plans or the intended use change.
Effective October 1, 1989.
This is to certify that the information provided is correct to tree:
best of my knowledge, and I understand I am responsible for all
charges incurred from this application.
�j
Date Sign ure
Directions to Property:
4-- J LJ l �C`14a .`1
Home Phone %`5-
-//e 111.^
Business Phone
_ %�5 - O�
2.
Name on Permit if
Different than
Above
3.
Property Owner if
Different than
Above UE.Y
4.
Application/Permit
For: C) General Evaluation
0 S/Tank Installation
S.
System to Serve:House
J Mobile Home
Business
Industry
u Other
0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#�
No. of People Dwelling Dimensions VX -5'-0 C�•�� �yX� `f
No. of Bedrooms ,2 asement/Plumbing
,No. of Bathrooms_ ` Basement/No Plumbing
(\ Washing Machine Dishwasher 0 Garbage D:ispusat
7. If business, industry, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers
8. Type of water supply: V Public XPrivate Community
9. Property Dimensions
10. Sewage Disposal Contractor "-
11. Do you anticipate additions/expansions of the facility this system is
intended to serve? fr. Yes XNo
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of 5
years from date issued. Improvements Permits are subject
to revocation, if site plans or the intended use change.
Effective October 1, 1989.
This is to certify that the information provided is correct to tree:
best of my knowledge, and I understand I am responsible for all
charges incurred from this application.
�j
Date Sign ure
Directions to Property:
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