The URL can be used to link to this page

337 Greenhill RdAccount #: 990002790 Billed To: Todd Earnhardt Reference Name: Proposed Facility Residence ATC Number: 3980 DAVIE COUNTY HEALTH DEPARTMENT ,a Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5728-35-0536 Subdivision Info: Location/Address: 337 Greenhill Road -27028 Property Size: 2.83 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 ARS. 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. d" /�Fl�tO Septic System Installed By: Environmental Health Specialist's Signature: �/ Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT �� f Environmental Health Section P. O. Boz 848/210 Hospital Street / Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002790 Tax PIN/EH #: 5728-35-0536 Billed To: Todd Earnhardt Subdivision Info: Reference Name: Location/Address: 337 Greenhill Road -27028 Proposed Facility Residence Property Size: 2.83 acres ATC Number: 3980 **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 1? #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 Zl--Repair ❑ System Specifications: Tank Size GAL. Pump Tank GAL. Trench Widthf Rock Depth Linear Ft.� Other:�e".��Scarltc�il STC/ �%iL ��i��✓C. Required Site Modifications/Conditions: 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.**** 4 Environmental Health Specialist's Signature: Dat v DCHD 05/99 (Revised) �Q PP ATION FOIi SITE EVALUATI ON/IAIPROVEAI ENT PERAUT & ATC Davie County Health Department SPC, 3 Environmental Health Section SFS' P.O. Box 848/210 Hospital Street Mocksville, NC 27028 p (336) 751-8760 ** PORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED y NFORMATION 15 PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed &/-)/// ) Grim'.✓!% Icol Contact Person Mailing Address _3 32 614EZV/`%/,,LL// /-�•F• Home Phone City/State/ZIP ��-/SS`ll�� /y(� ��L Z� Business Phone l�„"�q Z— —7 (~l % 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: c-siouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. Type system requested: ❑ Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People # Bedrooms # Bathrooms 12bishwasher ❑Garbage Disposal 29asLng Machine _asement/Plumbin ❑Basement/No Plumbing��_ 7. If Business/Industry /Other: verify type # Commodes # Showers # Urinals IF FOODSERVICE: # Seats 8. Type of water supply: ("County/City # People # Sinks # Water Coolers Estimated Water Usage (gallons per day) ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes El -No If yes, what type? ***I/t1P0RTANT*** CLIENTS MUST CODfPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOIV. Either a PLAT or SITE PLAN AIUSTBE SUBMITTED by the client witli THIS APPLICATION. Property Dimensions: I0 ` S-31 ck— WRITE DIRECTIONS (from Mocksville) to PROPERTY: • Tax Offlcc PIN: 11 S( '7 2 3 S (% t'Q u) ( &2 Property Address: Road Name City/Zip If in a Subdivision provide information, as follows: Name: / Section: Block: Lot: Date honk corners flagged: L31 t/v 5s 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 t11e 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 IIcalth 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. _ DATES / '� i "G SIGNATURE TIIIS AREA MAY BE USED FOR DRAWING YOUR SITETLAN (Include all of t11e following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). . :� te,,A, Sign given G —,Revised DCIID (05103 �-✓ 75 Site Revisit Charge Datc(s): Client Notification Date: EIIS: Account No. ` �.. Invoice No. 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 ❑ RECONNECTION ❑ Name: IOU Phone Number: 41 a ' '7 1 (Home) Mailing Address:_ 3 3 1 G re_zN VNj 1 PcQ x'1.1 oc-t . 2 7oZP (Work)' Detailed Directions To Site: G '� w - i . L TT GrP e.,_ 1N. l t P& - �>14 ►i,. to c,, le p a- -J p e �I1 Grrhss FY„v._ vl-Ac ►air ,% fie_ RFS. Property Address: -Z& M o LI4t j .1 4 VI C 2_7,3Z -f" Please Fill In The Following Information About The Existing Dwelling: Name System Installed Under:I—Od c0 Type Of Dwelling: M H Date System Installed(Month/Day/Year): 5_1 9 Number Of Bedrooms: Number Of People: °z• Is The Dwelling Currently Vacant? Yes ❑ No 13" If Yes, For How Long?. Any Known Problems? Yes ❑ No 1Z If Yes, Explain: Please Fill In The Following Information About The New Dwelling: Type Of Dwelling: Number Of Bedrooms: Number Of People: -3 Requested By:r X10. I,\, 1�1_' For Environmental Health Office Use Only d r Approved 011 Disapproved ❑ Comments: Environmental Health Requested: '"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 5` oney Order ❑ # I : L % 7i Amount: $ � O !" Date: ,I Paid By: �c✓`� r-� �f_ f" Received BY: �' ✓ Account #: )L % `% Invoice ' . �� y ✓xo AUTHORIZATION NO: 1163 DAVIE COUNTY HEALTH DEPARTMENT . Environmental Health Section PROPERTY INFORMATION Permittee'.s..�� P.O. Box 848 Name: � di Mocksville, NC 27028 Subdivision Name: Phone #: 704-634-8760 Directions to property: '. L r � AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Section: Lot: Tax Office PI/(N�1:#. V_ fay— - ZAV r� Road Name: LTy"' G rl �I I � 1 Z .0 a **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) 7JJ` �, . .`'1 " / n, _� ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION /,/S1l, Z--,� ��t .f ^ / ' f g IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS _g? # BATHS #OCCUPANTS �,_ GARBAGE DISPOSAL: Yes or No --COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No »LOT SIZE TYPE WATER SUPPLY �_ DESIGN WASTEWATER FLOW (GPD) NEW SITE v REPAIR SITE .... 11 SYSTEM SPECIFICATIONS: TANK SIZE IOTI GAL. PUMP TANK GAL. TRENCH WIDTH �6� / ROCK DEPTH �� LINEAR FT. REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BET- EEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760. OPERATION PERMIT SYSTEM INSTALLED BY: AUTHORIZATION NO. �� OPERATION PERMIT BY: DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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. DCHD 05/96 (Revised) IEs