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271 Gladstone RdDAVIE COUNTY HEALTH DEPARTMENT tEnvironmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000932 Billed To: Liberty A.M.E. Zion Church Reference Name: H.E. Houston Proposed Facility: Church P /,N --0o Tax PIN/EH #: 5736-948225 Subdivision Info: Location/Address: 271 Gladstone Road -27028 Property Size: 2.2 Acres ATC Num ber: 2281 **NOTE** T�i3is 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 #Baths Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: 13 Commercial Specification: Facility Type&"�-L #People #People/Shift #Seats Industrial Waste: 13 Lot Size Type Water Supply C Design Wastewater Flow (GPD) / Site: Newer Repair ❑ System Specifications: Tank Size/ 60 GAL. Pump Tank GAL. Trench Width Rock Depth Linear Ft.%DCS, 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.**** Sia Uil Environmental Health Specialist's Signature: Gig ' �.� Date: �� r � DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990000932 Billed To: Liberty A.M.E. Zion Church Reference Name: H.E. Houston Nroposea r-acinty: t;nurcn ATC Number: 2281 Tax PIN/EH #: 5736-948225 Subdivision Info: Location/Address: 271 Gladstone Road -27028 Size: Z.Z Acres 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: �, 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: /�/ -,y YSAQ22 Environmental Health Specialist's Signature: Date: — P t DCHD 05/99 (Revised) APPUCATION FOR SITE EVALUATION/IMPROVEMENT PERMIT A ATC Davie County Health Department Environments! Had& Secdon NOV 3 01099 P.O. Box 868/210 Hospital Street Mookaviller VC 27028 (336)751-8760 ***VVCRTAH?*** THIS APPLICATION Clll!'m= BB PR mssim UNL168S ALL THE RZQMMM I 1111PORM11TION 18 RROVIDBD. Rotor to the 11MORMATION BULLZVW for instructions. yam 1 • Maas t0 be Gilled /� ' + C� • r ( l Con"at Person hailing address • C O some inose city/state/3=p Ooolee e �LIL . "-?ZLY sosinese phone L Z. Mere oa pernit/A= if Different then Above V Mailinq hddrDee �%// /Citg/s to/fip u aiam Bvaauation 19631provement 1?4=it/ATC 0 Both e. systm to service: 13 House 0 Mobile Hone 0 Business 0 Industry "Oer►y"yI--`.� 1om % S. If Residence: i People f Bedros s Bathrooms eMt O Dishwasher 0 gsrbags Disposal 0 Washing Haohim 0 Mass o f/plvmbing 0 assament/Ho plumbing 6. t9 auainess/Iadustcy/other: specify type # Davie • $Lake i Commodes I showers i Urinsls # Water Coolers rF 11=8TJ=Cs: # Seats =stimated Water Usage (gallons par da]r) 7. Type of Water supply: 3 County/City 0 Well 11 Community 9. Do you anticipate additions or expansions of thefaeWty this system Is Intended to nerve? 0 Yes n No Uyes, what type? AJJJ; d k( - d f l u r el S�1/0&-Vs L h b X41' ***I1IIPOR7ANT*** CLIENTS MUST COMPLETETHE REQU7KED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN UWT BESVBMITIED by the client with THIS APPLICATION. ProoertY Dimeaeiona ,� LG�/tt-G�� nr*.a n�ens.�........._ �. a.....■..ua.ravtro r.�om jrige ViY 1 1 id i°ii'.1iC dfl fs Tax Office PIN: # S'" 'l fin- Jt'� � ' �?� fly p � Property Addresst Road Name a 1 l 4IrC46nf 'kD. c d-1,(- r� xoi City/Zip/l/ClC� ut I ice. A/,,C' 0' v u,--eol U in a Subdivision provide Information, as follows: 0Z'--' Name: Section: Block: Lott Date Property Flagged: Tab is to certify that the information provided is correct to the but of my knowledge. I understand that any permit(s) Issued hereafter are subject to suspension or revocation, it the site plans or Intended we change, or if the Information submitted in this application Is falsified or changed I, also, understand that I am responsible for all charges Incurred)irom this appilcadon. 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 luting procedures as necessary to determine the site ndtsb ty. DATE /a/res%94 SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property Ilea and dimensions, structures, setbacks, and septic locations). Site Revisit Charge IDate(s)t I Client Notification Date: IEHS: Revised DCHD (07/99) v Account No. Invoice No. MV