1521 Fork Bixby RdDAVIE COUNTY HEALTH DEPARTMENT
• • Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990002211
Billed To: Xiomara Infante
Reference Name:
:Ir000sed Facilitv: Residence
ATC Number: 3102
Tax PIN/EH #:
5779-06-6260.X1
Subdivision Info:
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Location/Address:
Fork Bixby Road -27006
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 .1 age Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWA N RU ION I ALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature. Date: 2&A /OZ
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.
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Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
' P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account M 990002211
Billed To: Xiomara Infante
Reference Name:
Proposed Facility: Residence
Tax PIN/EH #: 5779-06-6260.X)
Subdivision Info:
Location/Address: Fork Bixby Road -27006
Property Size: see map
ATC Number: 3102
**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
CTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type �p" � • � Iy AC #People '4 #Bedrooms 3 #Baths 2
Dishwasher: G?'*' Garbage Disposal: ❑
Commercial Specification: Facility Type
Washing Machine: C?'*' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
#People #People/Shift #Seats Industrial Waste: ❑
Lot Size 0. '� q 2 LOkType Water Supply wJNV� Design Wastewater Flow (GPD) 3toO Site: New 91""' Repair ❑
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System Specifications: Tank Size I DCOGAL. Pump Tank GAL. Trench Width � RockDe(2 Linear Ft. —"3�
Other: 3 0151-" b 0 T10') - �, 1 NSTAL-t- l oer
Required Site Modifications/Conditions. Co✓7ariz, va---f 5 p 96en r - 10 e*,
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 m km. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.****
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Environmental Health Specialist's Signature: - Date:
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DCHD 05/99 (Revised)
L6
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Health Department
EnvironmentaiHealth 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 INFORMAT/IO B TIN for instructions.
1. Name to be Billed �� D / •v (�-� . /�/?'(�/Lti e/ls() Contact Person
Mailing Address �Cp l�c t fi Ph /►�^-� �fe Home Phone -/ /, S v �/
City/State/ZIP G Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: ❑Site Evaluati Ly�mprovement Permit/ATC ❑ Both
4. System to Service: ❑ House Mobile Home ❑ `Business ❑ Industry ❑ Other
5. I£ Residence: # People / # Bedrooms � # Bathrooms
Dishwasher ❑ Garbage Disposal 'W -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
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes VNo
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERi'Y INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions: 5-e-'�
Tax Office PIN: # � -7
Property Address: Road Name F'
City/Zip /lc e C Z 7 0 4
If in a Subdivision provide information, as follows:
Name:
Section: Block: Lot:
WRITE DIRECTIONS from Mocksville) to PROPERTY:
53 5-6
.B 1
Date Property Flagged: 3 Z. o / D -5
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 responsihle 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.
DATE 1 SIGNATU
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of tlic following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
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Revised DCHD (07/99'��' �
Site Revisit Charge
Datc(s):
Client Notification Date:
EHS:
Account No.
Invoice No. O
(1.80 A)
3069
DAVIE BAPTIST
TABERNACLE
(2.30A)
4718
N
W
O
bo
O
(3.14A)
7674
•
7217
0.892AC
H7 0 06408
r26
779066126
0 �o
5071
(1.04A)
7821
MSO
60